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Practice Impact Studies

Practice Impact Survey: New Study

The form below can be downloaded as a Word Document.

  1. What is the purpose of your study?
  2. What is the duration of your study and expected start date?
  3. When do you anticipate CHR approval (if applicable) and funding to begin?
  4. Do you have funding to support possible costs associated with implementing your study in the practice?
  5. Do you want assistance with estimating costs if you are still determining them?
  6. 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)?
  7. What would your next steps be if your study is successfully implemented?
  8. 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.