Healthcare Research QI Support Intake Form

Name of primary contact for this project:

Position/Department:

Campus Mailing Address: (optional)

Phone (306-xxx-xxxx)

Pager #: (optional)

Email:

Fax (306-xxx-xxxx): (optional)

If you are not the Principal Investigator/Supervisor (i.e. faculty member) for this project, please provide the supervisor's name and department:

Do you have the ethics approval for this study?

Stage of research:

Results likely will be published as:

Is this project related to a degree or course requirements:

Is this project quality improvement focus research? (i.e. directly aims to improve patient outocmes, improve the quality of healthcare services):

Please provide a brief description of the quality improvement focus of your research (Quality metrics including accessibility, effectiveness, efficiency, patient-centred, safe, timely, equity)

Give a brief description of the scientific background and the specific aims of the study. What data is to be used to achieve these aims? (optional)

Give a brief description of the data (if any) you have collected: (optional)

Indicate important time deadlines: (optional)