RIDOC Planning and Research | Department of Corrections

Title of Research Proposal

Principal Investigator’s Name

First

Last

Organization

Phone Number

Email Address

Date Research Request Submitted

Please do not enter past dates

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.

Please provide a comprehensive narrative or project abstract that summarizes the proposed research and the need for that research

Goals and objectives of research

Measurable outcomes

Population of interest (e.g., awaiting trial, sentenced, and/or community corrections)

Description of selection criteria for records

Will any identifiable information (e.g., PII such as name, DOB, inmate ID) be requested?

Yes

What identifiable data will be requested? If de-identified or anonymized data is not sufficient, please explain why.

Will you be linking individual-level data to any other data?

Yes

What other data sets and/or data sources will be utilized and how do you propose linking?

Please describe the security procedures to be followed to protect the privacy of participants’ data

Project or Funding Deadline

Yes

Deadline Date

Description of anticipated finished product (e.g., presentation, journal article, paper for school)

Does this project have IRB approval?

Yes

Why was IRB approval not sought for this project?

Please attach IRB application and proof of IRB approval

One file only.
15 MB limit.
Allowed types: rtf, pdf, doc, docx, jpg, jpeg, png.

Is the research requestor a student?

Yes

Supervisor Information

Academic Advisor’s/Professor’s Name

First

Last

Job Title

Institution

Email Address

Phone Number

Funding Source (if applicable)

Is this research required to satisfy an academic requirement (i.e., Master’s Thesis or Doctoral Dissertation?)

Yes

What is the academic requirement and the proposed timeline to complete it?

Is this a primary data collection, behavioral health research, or medical research request?

Yes

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

Date of Application

Please do not enter past dates

Estimated Completion Date

Please do not enter a past date

Project Title

Project Short Title

Principal Investigator

Title

First

Last

Suffix

Phone Number

RIDOC Facilities/Units Involved in Project: (check all that apply)

High Security Center

Medium Security

Probation

Intake Service Center

Minimum Security

Parole

Maximum Security

Women’s Facility

Home Confinement

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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Additional Documentation

Maximum 5 files.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

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