Fields with a red star (*)are required.

Do you have an IRB Number?
Will the MCW IRB rely on an outside IRB for this project?

You will be required to upload the completed reliance agreement or the e-mail statement of approval from the MCW IRB Reliance team.

Project Staff Information

Primary Research Team Contact Information
Invoicing Contact Person Information

Sponsor Information

Funding Source

Project Information

Type of Project
With waiver of consent and authorization
For example:
  • Consent management-only projects (Consenting Froedtert Health patients for access to their PHI is the only Froedtert Health resource being used, with no invoicing or claims management requirements)
  • Invoice-only projects where there are three (3) or less Froedtert Health resources to be ordered as normal and invoiced to the study (for example, Froedtert Health imaging services such as MRI, CT, X-ray, Echo)
  • Use of only Froedtert Health IDS, but all other activities take place in MCW space
  • Request for Letter of Support (LOS) for Grant Application (upload a statement of commitment - e-mail or other documentation - from the leadership supporting your project if applicable)

*STOP*

You do not need to get Froedtert Health administrative approval if your project is solely data collection with an IRB-approved waiver of consent and authorization. All you will need to do is complete the web-based Accounting Log Form.

*STOP*

For this type of request, use the Additional Details free-text box to communicate your intended plan in lieu of an Operational Feasibility Tool.  Upload the documents that are pertinent to your limited-use project (protocol summary, ICF, imaging guidelines, etc.). 

 

For CCCTO Clinical Trials Only: Will the MCA be outsourced to GuideStar?

For this type of Innovative Care project, a completed Operational Feasibility Tool is NOT required at time of this application.

Does this project require services, resources, or support from a Froedtert Health affiliate or will it be conducted in a Froedtert Health affiliate location?

*STOP*

You do not need FH administrative approval if your project will not use any Froedtert resources and all research activities will be conducted in MCW space. If you are unsure whether the resources involved in your project are FH resources, do not complete an application, contact us at ocricc@froedtert.com or 414-805-4082 to discuss.

Does this project require radiology, cardiology, or other images to be sent to sponsor throughout project?
Does this project require pricing for any Froedtert Health resource/service(s)?
Did you obtain any preliminary pricing via the Froedtert Health Research Chargemaster?
Do you require any additional pricing for Froedtert Health resources or services?
Did you obtain preliminary pricing from OCRICC via the Request for Froedtert Health Research Pricing Application?

Service Descriptions and CPT Code Instructions

For most efficient service, research staff should identify CPT codes for the services needing to be priced.

  • If there is no CPT code, research staff should identify a CPT code for a comparable procedure, making note of this detail on the request form.
  • If the correct CPT code or comparable CPT code/procedure is not known, research staff should ask the sponsor or PI.
  • If the sponsor cannot provide, or PI does not know, the research team should contact their MCW Department resource that manages professional billing/coding.

Research staff can expect that, if they provide CPT codes for each service when requesting pricing, OCRICC will be able to complete these requests within 5 business days. Researchers submitting pricing requests without corresponding CPT codes may experience a delayed turnaround.

Re-order Service Description CPT Code Department Providing Service Weight Operations
more items
To add more lines, click the plus sign on the far right or enter the number of items in the box above and click the word "Add" to the left of it.
This number was provided to you when you submitted the Froedtert Health Pricing Application to OCRICC.

Project Documents

Attaching all required documents will support OCRICC’s timely and efficient operational and financial feasibility review. A project cannot be initiated without all required documents.

NOTE: If during the initial review of your application any project-specific documents are found to be missing, your application will be placed on hold and returned to you with instruction.

One file only.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.


Document must identify items/services as "Research" or "Standard of Care." See example in the MCA Guidance Document.
We will also accept:
•Comparable documentation of Research vs. Standard of Care
•A detailed statement of what is Research vs. Standard of Care
One file only.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

One file only.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Download the Operational Feasibility Tool PDF form.
One file only.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Include when applicable, and include for each imaging modality.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Include when applicable.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

One file only.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Include when applicable.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Include when applicable.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Include any additional documentation that is applicable to your project.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
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