Diabetes Research Connect Apply – Diabetes Action Canada

CPCSSN ID

Complete DAR package received

Fill out ALL fields in this form. Incomplete forms or missing information will be sent back to the researcher to complete

Primary Investigator (PI)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

University(Required)

Faculty(Required)

Department(Required)

CPCSSN Network (If applicable)

Do you have a collaborator / co-investigator? If yes, fill the following section “Collaborator(s) / Co-Investigators Information"(Required)

Yes

No

Collaborator(s) / Co-Investigators Information

If you have more than one collaborator / co-investigators, fill out additional individuals on the Additional Contacts page.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

University(Required)

Faculty(Required)

Department(Required)

CPCSSN Network (If applicable)

Is this project part of a trainee curriculum? If yes, fill the following section “Trainee Information”(Required)

Yes

No

Trainee Information

If you have more than one trainee, fill out additional individuals on the Additional Contacts page.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

University(Required)

Faculty(Required)

Department(Required)

CPCSSN Network

(If applicable)

Trainee Year

(e.g., PhD1, MSc2 etc.)

Do you have other research personnel? If yes, fill the following section “Research Personnel Information”(Required)

Yes

No

Research Personnel Information

If you have more than one research personnel, fill out additional individuals on the Additional Contacts page.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

University(Required)

Faculty(Required)

Department(Required)

CPCSSN Network

(If applicable)

Trainee Year

(e.g., PhD1, MSc2 etc.)

Do you have any additional contacts that you need to include?(Required)

Yes

No

Additional Contacts

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

University

Faculty

Department

CPCSSN Network

(If applicable)

Trainee Year

(e.g., PhD1, MSc2 etc.)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

University

Faculty

Department

CPCSSN Network

(If applicable)

Trainee Year

(e.g., PhD1, MSc2 etc.)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

University

Faculty

Department

CPCSSN Network

(If applicable)

Trainee Year

(e.g., PhD1, MSc2 etc.)

Project Information

Project Title

Has the project undergone a peer review process?

Yes

No

Which agency, committee, or institution?

Project Start Date

Project End Date

Data Cut Request

Option A: Full data cut (all records)

Select

Up Until Date

Option B: Cross-section

Select

From Date

To Date

Upload REB Approval Letter * (PDF)(Required)

*If the project has not received REB approval, you may not proceed with the DAR submission

Accepted file types: pdf, Max. file size: 64 MB.

Please provide a lay summary of the research proposal (250 Characters)

Upload your full research proposal document (PDF)(Required)

Accepted file types: pdf, Max. file size: 64 MB.

Document Checklist

DAR completed

SRE User Agreement

Complete Research Protocol

External Scientific Review, if available

SRE User(s) Access Form

Data Specifications

DAR Variable Request Form (Appendix 1)

Terms of Agreement

Signature(Required)

Name(Required)

First Last

Date of Signature(Required)

Appendix 1

CPCSSN Dictionary (DAR) Variable Request

Project Title

Principal Investigator(Required)

First Last

Please check off all variables requested that apply to your project. Please refer to the CPCSSN Data Dictionary and Entity Relationship Diagram to guide your choices. DATA SPECIFICATIONS Data Requirements (Please refer to the CPCSSN Data Dictionary for a detailed description of the data elements)

PRIVACY AND SECURITY POLICY We do not typically release any _orig (original information extracted from participating EMR’s) or open text fields. CPCSSN will only release age (Birthyear) and location (FSA) data in specific combinations: ▪ Birthyear and Urban/Rural status ▪ Age Brackets and FSA

1. Patient Age

Your study requires:

All patients

All patients with Birthyear

Birthyear ≥

AND Birthyear ≤

2. Birthyear and Location

Your study requires the following variable combinations (see note in box above):

Birthyear | Urban/Rural

Five-year age brackets | FSA (3 digit postal code)

If age brackets, please provide year at which age is calculated:

3. Original (_orig) and Free Text fields(Required)

NOTE: researchers will need to provide significant justification for requesting original and free text fields for CPCSSN to make an exception and provide this data type. Does your study require .orig fields:

Yes

No

Justification for requesting .orig fields

Apply