Form 1 Survey

OMB #: 0925-0550
Expiration Date: 07/31/2008

IECRN Core Survey

Sponsored by:
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892

Administered by:
Westat
1650 Research Boulevard
Rockville, Maryland 20850

Public reporting burden for this collection of information is estimated to average 15 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to: NIH Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0534-3). Do not return the
completed form to this address.

IECRN CORE SURVEY

Please enter the contact information of the person who is completing this survey. The asterisks indicate
required information.
*Name: _________________________________________________________________________
Title: ___________________________________________________________________________
Organization: _____________________________________________________________________
*Telephone: ____________________________

*Email: ______________________________

Please complete the questions below about the following clinical research network:

Part A. Background Information

A1.

Does your network conduct research involving human health or human behavior?
This includes the following types of human health or behavioral studies: clinical trials,
epidemiology, behavior modification, health communications, patient care, medical practice,
clinical quality improvement, and clinical process improvement. Surveillance systems and
registries should be included if there has been some human health or behavioral research
output.
Yes
No (Please briefly describe the type of research conducted by your network. Then skip
the remaining questions and go to the “Submission Instructions” box at the end of this
survey.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Not sure (please explain)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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IECRN CORE SURVEY

A2.

Does your network currently …
A2a.

Contain at least three independent or semi-independent participating entities?
Yes
No (please explain)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Not sure (please explain)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

A2b.

Carry out multiple studies, or have the intent of carrying out multiple studies?
Yes
No (please explain)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Not sure (please explain)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

A2c.

Have scientific leadership that either develops research ideas or critically
evaluates the ideas or protocols that are brought to it by outside investigators?

Yes
No (please explain)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Not sure (please explain)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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IECRN CORE SURVEY

A3.

Is this network currently carrying out research or conducting investigations?
Yes
No (please explain)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Not sure (please explain)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

A4.

Is this network actively planning future research or investigations?
Yes
No (please explain)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Not sure (please explain)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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IECRN CORE SURVEY

Part B. General Research Network Characteristics
Please complete the following questions by filling in the requested response(s) and/or
selecting the appropriate box(es).

B1.

In what year was your network established?
|__|__|__|__|
Year

B2.

Funding sources

B2a. What are the funding sources for your
network? (Please select all that apply.)

B2b. If you selected more than one funding
source in Question B2a, select the one
response that best describes the primary
funding source for your network, that is,
the source that provides the greatest
amount of funding. If you selected only
one funding source in Question B2a, skip
to Question B3.

U.S. Federal government (specify
agency/ies and institutes, e.g., NIH, NCI)
__________________________________
__________________________________
__________________________________

Select this box if there is no primary funding
source.
U.S. Federal government (specify
agency/ies and institutes, e.g., NIH, NCI)
__________________________________
__________________________________
__________________________________

U.S. state or local government
Government outside the U.S.
Academia
Non-profit
For-profit or commercial
Professional organizations
Other (specify) _____________________
__________________________________
__________________________________

U.S. state or local government
Government outside the U.S.
Academia
Non-profit
For-profit or commercial
Professional organizations
Other (specify) _____________________
__________________________________
__________________________________

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IECRN CORE SURVEY

B3.

Which of the following best describes the broadest geographic coverage of your
network? (Please select one response)
U.S. and country(ies) outside the U.S. (specify) ______________________________
Only country(ies) outside the U.S. (specify) _________________________________
More than one state in the U.S. (specify) ___________________________________
___________________________________________________________________
One state only (statewide) in the U.S. (specify) ______________________________
Regional within one state in the U.S. (e.g., more than one city, municipality, county)
(specify) ____________________________________________________________
Local area within one state in the U.S. (e.g., within one city, municipality, or county)
(specify) ____________________________________________________________

B4.

Which of the following entities participate in your network? (Select all that apply.)
Individual practitioner or group practice
Academic medical center or other university-affiliated health care facility
Federal or national government health care facility (e.g., U.S. Department of Defense
military treatment facility, UK NHS hospital)
State, local, or other regional health care facility
Other health care facility
Academic research center or other university-affiliated research facility
Health Maintenance Organization (HMO)
Clinical laboratory
Pharmaceutical company
Contract research organization
Foundation
Other (specify) _______________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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IECRN CORE SURVEY

B5.

Types of studies

B5a. Which of the following types of studies B5b. If you selected more than one type of
have been conducted by your network
study in Question B5a, select the one
since its establishment or over the past
response that best describes the type of
5 years (whichever is shorter)? (Select
study most frequently conducted during
all that apply.)
that time period. If you selected only
one type of study in Question B5a, skip
to Question B6.

Clinical trials, Phase I
Clinical trials, Phase II
Clinical trials, Phase III
Clinical trials, Phase IV
Field or community intervention trials (with
healthy subjects)
Other intervention studies, including
behavioral (specify)
__________________________________
__________________________________

Select this box if there is no particular type of
study conducted most frequently.
Clinical trials, Phase I
Clinical trials, Phase II
Clinical trials, Phase III
Clinical trials, Phase IV
Field or community intervention trials (with
healthy subjects)
Other intervention studies, including
behavioral (specify)
_________________________________
_________________________________

Observational epidemiology studies (e.g.,
case control, retrospective, prospective)

Observational epidemiology studies (e.g.,
case control, retrospective, prospective)

Other observational studies (specify)
__________________________________
__________________________________

Other observational studies (specify)
_________________________________
_________________________________

Outcomes research (e.g., delivery of care,
cost-effectiveness)
Best practice modeling
Methodological research
Other (specify) _____________________
__________________________________
__________________________________

Outcomes research (e.g., delivery of care,
cost-effectiveness)
Best practice modeling
Methodological research
Other (specify) _____________________
_________________________________
_________________________________

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IECRN CORE SURVEY

B6.

Please list the primary diseases, conditions, behaviors, or special subject areas that
are currently being studied by this network.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

B7.

Does this network currently focus specifically on… (Select all that apply.)
Children under the age of 18
People aged 65 and older
Males or gender-specific male illnesses or conditions
Females or gender-specific female illnesses or conditions
Minority populations
Underserved or rural populations
Any other special population (specify) _____________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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IECRN CORE SURVEY

Part C. Online Inventory Web Site Questions
C1.

Please consider including the information you have provided about your network in
Part B (General Research Network Characteristics) of this survey in an online
inventory. This inventory will be available to clinical researchers and other interested
individuals. Do we have your permission to list this Part B information in the publicly
accessible online inventory?
Yes, include my Part B survey responses in the online inventory.
No, do not include my Part B survey responses in the online inventory.

C2.

Please consider including network contact information for your network in the online
inventory. Do we have your permission to list your network contact information in the
publicly accessible online inventory?
Yes, include my network contact information in the online inventory.
No, do not include my network contact information in the online inventory.

C3.

If you agree to have your contact information included, please provide the information
as you would like it to be displayed.

Prefix:

First Name:

Middle
Name/Initial:

Last Name:

City:

State/Region/
Province:

Zip/Postal code:

Suffix:

Title:
Organization:
Department:
Street Address:

Country:
Telephone:
Email:
Web site:

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IECRN CORE SURVEY

SUBMISSION INSTRUCTIONS
Thank you very much for completing the IECRN Core Survey. Please make a copy of the
completed survey for your reference. If you have questions/concerns regarding this survey, please
contact us at 1-877-885-1122 or Help@clinicalresearchnetworks.org. If you are located outside of
the United States, please call collect using the following telephone number once you have
reached the United States: 240-314-7580.
Please return the survey in the enclosed prepaid envelope to:
Westat
Attn: Lauren Laimon
WB 413
1650 Research Boulevard
Rockville, Maryland 20850
Or fax it to 1-877-885-9653.
If you are outside of the United States, please use the following fax number after you have
reached the United States: 240-314-2559.

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