Practice Impact Studies
Practice Impact Survey: New Study
The form below can be downloaded as a Word Document.
- What is the purpose of your study?
- What is the duration of your study and expected start date?
- When do you anticipate CHR approval (if applicable) and funding to begin?
- Do you have funding to support possible costs associated with implementing your study in the practice?
- Do you want assistance with estimating costs if you are still determining them?
- Please outline the steps of how your study might impact the practice and who would be responsible for each step of the process:
- Are forms or data collection involved? Are you asking for patients to be approached in any way directly by practice staff?
- Are handouts or posters included?
- Do you need to tie back information to a PCP?
- Do you need to retain copies of any information in the medical record?
- Do one or more patient stickers need to be used in the processing of any forms? If so, how many?
- How does the provider use any form(s) or participate in the study?
- What steps are nurses asked to take during a patient visit and approximately how much time would these take?
- What steps are admin staff asked to take during a patient visit and approximately how much time would these take?
- Are other practice staff asked to be involved, during or outside of a patient visit?
- Are there other activities or supplies needed to fulfill the actions requested by the study (e.g. providing kits)?
- Is any follow-up requested by practice staff (e.g. inquiring if any action asked of the patient has been completed)?
- What would your next steps be if your study is successfully implemented?
- Do you need space in the practice for any of your activities?
Please return survey to Katie Mak in the DGIM Administrative Office, tel: (415) 353-7931, fax: (415) 514-8666, e-mail: Katie.Mak@ucsf.edu.