Employee Profile

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

o8IJKsZYuam4uProL8dYIhbWZVjMLoxSFqYUrxaof2dr

Hello!

This Employee Profile is the first step in completing Clinical Research Orientation and/or Clinical Research Training. Please complete this form in its entirety in preparation for orientation and training. There are forms that are required to be completed by your PI or supervisor. Please be sure to consult with your PI or supervisor as you complete this form.

If you already have an existing eCREST/EHC Credentialing profile please email OCR@emory.edu to update your profile. DO NOT create a new profile.

If you need to save and complete this form at a later time, please enter your email after clicking "Save and Return Later" DO NOT create a new profile.

If you need assistance or encounter any issues, please email OCR@emory.edu

First Name

* must provide value

Middle Initial

Last Name

* must provide value

Nickname (Preferred Name)

Email Address

* must provide value

Office Phone Number

* must provide value

Office Fax Number

Office Address

* must provide value

Expand

Job Title

* must provide value

Research Role

* must provide value

If "other" research role, please specify:

If "Other Research Clinician" research role, please specify:

* must provide value

Supervisor/Manager Name

* must provide value

Supervisor/Manager Email Address

* must provide value

Hire Date

* must provide value

M-D-Y

Supervisor/Manager Phone Number

* must provide value

Employer

* must provide value

If "other" employer, please specify:

Emory Net ID

(e.g. Jane12@emory.edu - Jane12 is the Net ID)

* must provide value

School (if applicable)

Examples: Medicine, Nursing, Public Health

Department

Examples: Medicine, Pediatrics, Radiology

* must provide value

Division/Program

Please choose your Principal Investigators employer:

* must provide value

Emory

CHOA or CHOA Affiliated Private Practice (if you work for both CHOA and Emory investigators, please choose "Emory")

other

reset

If "other" Principal Investigator employer, please specify:

Please select the campus/facility where you will be conducting research (choose all that apply):

* must provide value

Emory University

Emory Healthcare (Emory Hospitals, The Emory Clinic, Winship, or other Emory Affiliated Practice)

Emory Children's Center

CHOA or CHOA Affiliated Practice

GA Tech

Morehouse

Grady

Other clinical facility

None of the above - I will not be conducting research at a campus/facility (Ex. Remote Work, Winship Clairmont Annex, or other Emory administrative building.)

If "other" facility, please specify:

* must provide value

If "none of the above", please specify your involvement in research (administrative, future career, etc):

* must provide value

Please choose the Emory Healthcare facility where you will be conducting research (choose all that apply):

* must provide value

Emory University Hospital

Emory University Hospital Midtown

Emory Saint Joseph's Hospital

Emory Johns Creek Hospital

The Emory Clinic

Emory Decatur Operating Units

Winship Cancer Institute

Other clinical facility (ex. Kaiser)

If "other" facility, please specify:

* must provide value

Before you get started, it is important to know the research duties that you will be performing. You will need to discuss with your Supervisor and/or Principal Investigator regarding all clinical-related activities you may be performing within your role, as they will determine the training, immunizations, and additional requirements that you will need.

Please have your Supervisor/ Principal Investigator complete the attached Clinical Authorizations and Competency form to help determine if any additional competencies and training are needed.

Please Note If you will be conducting research at an Emory Healthcare Facility, you will need a designated Clinical Sponsor. Your Clinical Sponsor must be a physician, physician assistant, or nurse practitioner with site privileges at the EHC Facility where the research is conducted. In most cases, the Principal Investigator is the Clinical Sponsor if they are a clinician.

If you are a licensed and practicing physician, nurse practitioner, or physician assistant, you will not need to complete the Clinical Authorizations and Competency form or the Sponsor Physician Authorization form. Please contact Kim Cornell, Enrollment Manager at kim.cornell@emoryhealthcare.org to set up provider privileges at your EHC site.

Attachment:Clinical Authorizations and Competency Review 7.27.22.pdf

Please have your Clinical Sponsor Complete the Clinical Sponsor/Physician's Statement

Attachment:Sponsor Physician Signature and Designated Sites.docx

Clinical Sponsor First Name:

* must provide value

Clinical Sponsor Last Name:

* must provide value

Clinical Sponsor Email

* must provide value

Please upload the Clinical Authorizations and Competency form completed by your Supervisor or Principal Investigator

* must provide value

Upload file

Upload the completed Clinical Sponsor/Physician's Statement

Upload file

Please select all the clinical functions you will be performing in your job role. Refer to the Clinical Authorizations and Competency Form completed by your supervisor or PI.

* must provide value

Venipuncture (Phlebotomy)

Height/Weight measurements

Pulse Oximeter

ECG

Lab specimen processing, handling, shipping, or transport

Other invasive/minimally invasive clinical activities

Not Applicable

If "other clinical activities", please explain.

* must provide value

Expand

Will you require access to Emory Healthcare patient medical records (i.e. Powerchart, EPIC)?

* must provide value

Yes

reset

Will you work with blood, tissue samples, and/or cell cultures?

* must provide value

Yes

Unsure

reset

Will you participate in research activities involving work with hazardous chemicals? (i.e. ethanol, dry ice, etc.)

* must provide value

Yes

Unsure

reset

Will you have to package and/or ship any biohazard material or dangerous goods? (i.e. blood, plasma, dry ice, etc.)

* must provide value

Yes

Unsure

reset

Will you be working on a clinical trial as defined by the NIH (which includes FDA-regulated studies) at Emory?

Review the IRB's FAQ page question "Is my study FDA-regulated" for more information.

* must provide value

Yes

reset

Will you work on ANY of the following?

1. A study that has Emory Healthcare billable items/services (i.e. CPT or CDM code).

OR

2. A clinical trial study with an Emory investigator with no Emory Healthcare billable items/services (i.e. CPT or CDM code), but requires Clinicaltrials.gov registry?

More detailed information can be found here: http://www.ocr.emory.edu/ct.gov/index.html

* must provide value

Yes

reset

Select your years of clinical research experience (i.e. experience as a research coordinator, regulatory, administrative, investigator, etc.)

* must provide value

0-2 Years

2-5 Years

5-10 Years

Over 10 years

reset

Are you new to Emory?

* must provide value

Yes

reset

Emory Sponsored Account Net ID

Please upload your most recent resume.

* must provide value

Upload file

For information on CHOA research credentialing, training, and access, please contact: researcheducation@choa.org

Contact Emory at the Grady Research Office at egr.docs@emory.edu to get started with Grady Hospital Credentialing.

Please review the Grady Office of Research Administration website: https://gradyhealth.org/static/office-of-research-administration/

To begin your credentialing process at the VA, we will need additional information from you to provide to the VA Office of Research and Development

Name of VA Principal Investigator

* must provide value

Short title of the study protocol

* must provide value

IRB number for the protocol conducted at the VA

* must provide value

Contact Clayton Carruth in the Office of Research and Development at edwin.carruth@va.gov for credentialing at the VA.

Please review the VA Office of Research & Development website: https://www.atlanta.va.gov/services/research/Investigators.asp/

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.