Perioperative Database Project Request - Anesthesiology Department

Name of Project*

Type of Research Request

Approval Obtained

Name of Applicant*

Email*

Sponsoring Faculty Member*

Other Faculty/Residents/Fellows Involved

Project Due Date*

Research Plan

Purpose of Project*

Please include the hypothesis and main objective of this study or project. What will the results be used for - publication, grant proposal, QI, administration...etc? If QI, please specify exactly how these will be used to improve quality.

Background and significance

Preliminary Data

Perioperative Data to be obtained and analysis plan

include estimated number of cases and who will do analysis