Principal Investigator’s Name

Please make one selection where applicable and fill in any corresponding information. Attach any supplemental documentation where applicable, or at the end of this form.

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Supervisor Information
Academic Advisor’s/Professor’s Name
Is this research required to satisfy an academic requirement (i.e., Master’s Thesis or Doctoral Dissertation?)
Researchers seeking to conduct primary data collection, behavioral health research, or medical research are encouraged to contact the Administrator of Planning and Research in advance of their application, as well as review the Medical Research Advisory Group (MRAG) forms that can be found on the Planning & Research web page under “Research Policy Forms"
MRAG Research Application Form
Please do not enter past dates
Please do not enter a past date
Principal Investigator
Title
RIDOC Facilities/Units Involved in Project: (check all that apply)

Please provide the following information with your application:

Abstract
Questionnaires
Copy of IRB Application
Copy of IRB Approval
Funding source/funds availability
Names of individuals requesting RIDOC security clearance/badges
Completed Confidentiality Pledges
Number of patients to be enrolled

NOTE:

Every six months, (June and December) an Update Report must be filed with the Medical Program Director/MRAG and the Administrator of Planning & Research. All correspondence and questions regarding this process should be directed to:

Medical Program Director
Medical Research Advisory Group
Rhode Island Department of Corrections
39 Howard Avenue
Cranston, RI 02920
Phone: (401) 462‐1115
Fax: (401) 462‐2000

Administrator, Planning & Research
Planning & Research Unit
Rhode Island Department of Corrections
18 Wilma Schesler Lane, Dix Bldg., 1st Floor
Cranston, RI 02920
Phone: (401) 462‐3920

By submitting this request form, you attest that you have read and understand RIDOC’s Research Policy and agree to adhere to the guidelines set forth therein, including compliance with acknowledged professional and scientific ethics, as well as State and Federal guidelines (see 45 CFR part 46, Subpart C)

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