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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.

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Required format:

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Zmmp4V8mbVMSXz9iWRrV

Qualtrics Account Request for OSUWMC Faculty and Staff

Thank you for your interest in upgrading your OSU Qualtrics account. Please answer the questions below to assist us in understanding your needs. The contacts for Qualtrics at the OSU Wexner Medical Center are:

Heather Lansky
Jess Hale
Mary Shook (alternate)

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Date:

Y-M-D H:M:S

There are two pre-requisites before your Qualtrics account can be upgraded:

You have established a default account through http://osu.qualtrics.com. You must set this up with your lastname.# OSU account, not your Medical Center username.
After completing SSO, you should have seen the following Qualtrics pop-up window, and selected the second option: "No, I don't have a preexisting account here". If you DID NOT select the second option, please login to http://osu.qualtrics.com with your lastname.#, and select the second option. This is necessary for your default account to be created under the OSU Qualtrics instance and we will be unable to upgrade your account until this is complete.
: "No, I don't have a preexisting account here". be upgraded
Completion of HIPAA and Institutional Data Security FY21 or HIPAA and Institutional Data Compliance FY22 Annual. Your training status will be confirmed in BuckeyeLearn, so if you have not completed it your request will not be processed.

Your account cannot be upgraded without both the trial account and current IDP completion.

Your certificate should look like one of these

Do you have these prerequisites completed?

* must provide value

Yes, I am ready to proceed with the upgrade request.

No, I do not have the prerequisites completed. (You will have come back later to request an account upgrade).

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Please upload a PDF of your Institutional Data Policy FY20 or FY21 here

Upload file

Your First Name
Your Last Name
Your Email
Your Job Title
Your Medical Center username: (example: smi01)
Your OSU name.# (example: smith.123)

Your role at OSUWMC:

* must provide value

Faculty

Director or Manager

Administrative Assistant

Staff (non-nursing)

Staff Nurse

Resident

Student (Student Employee, Undergraduate, Graduate, Postdoc)

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College/Department

* must provide value

OSU Wexner Medical Center (including all hospitals and departments - e.g., James, Harding, Ross, UH, etc.)

College of Medicine

College of Medicine - Research Information Technology

Other

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Other College/Department

Which OSUMC entity do you work for?

Administrative Office (Legal affairs, HR, etc.)

Ambulatory (Primary and Specialty Care)

Brain & Spine Hospital/Neurosciences Institute

College of Medicine

James Cancer Hospital & Solove Research Institute

OSU Harding

OSU Health Plan

Ross Heart Hospital/Davis Heart & Lung Research Institute

Shared Services

Sports Medicine

Stefanie Spielman Comprehensive Breast Center

University Hospital

University Hospital East

Other not identified above

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Other OSUWMC entity

IMPORTANT!!
We need a record of your manager's approval for you to receive an upgraded Qualtrics account.

Do you have an email, verifying your manager's approval, available to upload?

Please upload a PDF copy of the email verifying your manager's approval of your Qualtrics upgrade request.

* must provide value

Upload file

Please provide your manager's name and email address. An approval form will be sent to them to complete.

Manager's Information
First Name
Last Name
Email

What will you be using Qualtrics for?
Select all that apply.

* must provide value

360 Review (Peer Evaluation)

Evaluation post workshop, meeting, or event

Event registration

Evidence-based Practice (EBP)

Quality improvement

Research study

Access to a survey someone else has already created

Other

Brief description of survey purpose

* must provide value

Expand

Depending on what data you are using and how it will be shared, you may need to submit a Data Quality Release Form (DQRF) and get approval for your Quality Improvement project.

Please review the policy and process document linked below.

Attachment:

DataQualityReleaseFormInstructions.pdf

Are you sending the survey

Internally (within OSU only)

Externally (to people outside OSU)

Both internally and externally

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Who are you sending the survey to?
Select all that apply.

Patients

Faculty

Staff (non-nursing)

Staff nurses

Residents

Students (Student Employee, Undergraduate, Graduate, Postdoc)

External persons (non-OSU) who are not patients

Other

What other audience are you sending the survey to?

What specific group of faculty, staff, or residents?

Within my department only

Faculty, staff, and/or residents outside my department

Both within my department and external to my department

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Please upload a copy of your survey.

Upload file

Please upload a copy of your survey.

Upload file

Who is the Principal Investigator on the research study?

* must provide value

Principal Investigator's Email

* must provide value

Research Study title

* must provide value

Expand

Are data being collected at multiple time points?

* must provide value

Yes

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What is the highest level of data you are collecting?
Unsure? Check the Institutional Data Policy Calculator

* must provide value

Public (S1)

Internal (S2)

Private (S3)

Restricted (S4)

I don't know

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The collection of Protected Health Information (PHI) or Research Health Information (RHI) in Qualtrics is not universally approved.

REDCap is approved for, and is the preferred application for S4 data collection due to the security controls REDCap has in place.

Are you interested in using REDCap for S4 data collection?

* must provide value

Yes

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Follow the instructions on the new REDCap project request webpage to request a new REDCap project for S4 data collection.

Once you submit a request, a member of the RIT EDC team will be in contact with you.

Please continue filling out the Qualtrics request form. We will keep your submission on file, in case you require a Qualtrics upgrade is needed.

To use Qualtrics for S4 data you must also contact Medical Center Risk Assessment for approval.

Regulatory status of the protocol

* must provide value

IRB exempt

IRB not submitted

IRB submitted

IRB approved

IACUC submitted

IACUC approved

Other

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IRB number

* must provide value

IACUC number

* must provide value

Will you be collecting informed consent in Qualtrics?

* must provide value

Yes

No (i.e., the consent document will be collected on paper)

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Does the informed consent require a signature?
Typically, these are studies that involve more than minimal risk to participants.

* must provide value

Yes

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The university has a detailed electronic signature policy and guide to implementing electronic signatures that are legally binding, recognized by the university, the state of Ohio, and the federal guidelines for electronic signatures.

Qualtrics has an electronic signature feature that meets university requirements for a legally binding electronic signature when configured appropriately. The authenticity requirement for electronic signatures can vary in Qualtrics depending on the protocol.

Additionally, the IRB requires use of an approved electronic signature method or written approval from OCIO.

We will work with you to determine if your project meets these requirements.

Which of the following will you be collecting?
Select all that apply.

* must provide value

Patient-reported outcomes

Patient-reported experiences (i.e., satisfaction)

None of these

Have you considered using REDCap for this study?
REDCap provides several benefits over Qualtrics in longitudinal data collection.

No but I would like to hear more about REDCap

No and I'm not interested in REDCap

Yes and I prefer to use Qualtrics

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We'd like to learn more about your decision in order to help us guide other researchers in their choices.

Will you elaborate on your decision not to use REDCap?

Expand

Are you interested in on-campus Qualtrics training when it becomes available?

Yes

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Survey Type field from Excel

Expand

Survey Reviewer field from Excel

Expand

Notes field from Excel

Expand

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.