Greenphire ClinCard Study Request Form Use this form to request the set-up of your study in the ClinCard application. Fields marked with an asterisk (*) are required. Requestor Contact InformationPlease enter your contact information as the person who is submitting this ClinCard study setup request. Your Name* First Last Your Email* Enter Email Confirm Email Study InformationEnter details about the research study. Study Name*Enter a short nick name of your study Principal Investigator (PI) Name* First Last Principal Investigator Email* Study Department Number*Enter the study's four digit department number. Use the budget site to lookup an appropriate value at https://budget.uconn.edu/university-organizational-structure/. Sponsored Program Services (SPS) InfoEd Proposal/Award Number Please lookup this value in InfoEd at https://www.infoed.uconn.edu if needed. Study KFS Account*This will be referred to as the Study Number in ClinCard and will be the account that will be charged for the incentive payments made to study participants. Institutional Review Board (IRB) Number* Study Human Subjects/Incentives Budget*Please enter the estimated total of all payments expected (i.e. the amount approved in your award budget) that will be made through ClinCard during the course of the study. The value entered here does not control encumbrances on your account.Please enter a number greater than or equal to 1.Is the study open to UConn faculty, staff, and students only?* No Yes Will this study be providing $100 or more in aggregate total payments to any one participant for participating in the study?* No Yes Will it create an undue burden on the researcher and/or research participants if social security numbers are collected and entered into the ClinCard system?* No Yes Unsure Note: Name, address and date of birth are required to set up a research participant in the ClinCard system. Social security numbers may be required where participants are likely obtain more than $600 in incentive payments from one or more UConn studies to assist with 1099 taxable income reporting from the University. Please explain why collecting this data from each participant would place an undue burden on the researcher, hamper recruitment efforts, and/or place additional risk on participants due to a potential breach in confidentiality.*Payment Schedule*Please create or attach a list of the scheduled payments that will be made to participants and the associated payment amount. This list will appear in the system to make the payment process more efficient for the Study Coordinator. Payment Description (e.g. 1st Visit, 2nd Visit, Survey)Payment Amount ($)Order of Payments (Enter an Integer) Attach list of scheduled paymentsMax. file size: 100 MB.Study User RolesEnter the names of the study coordinators and approvers who will need access to this study regardless of whether or not they have a ClinCard account. Will one study coordinator be responsible for both registering study subjects and making payments to study subjects?* Yes No Study Coordinators*Please enter the names of all the Study Coordinators that you anticipate will be making payments to subjects. Please enter their name even if they already have access to the ClinCard system.First NameMILast NameUConn Email AddressPhone # ApproversPlease enter the name(s) of the individuals (besides the Principal Investigator) who will have the authority to approve manual payments. Note: Please do not include any study coordinators. Study coordinators who are issuing payments cannot also approve payments. First NameMILast NameUConn Email AddressPhone # ClinCards RequestedIf you need an initial set of ClinCards to use with this study, please only request the number of cards that will be used within the next 4-6 weeks. Please allow 3-5 business days for delivery time. Additional cards can be ordered at a later time.Are you requesting an initial order of ClinCards to use with this study?* No Yes Initial Number of ClinCards Requested*Please enter a number greater than or equal to 0.Please only request the number of cards that will be used within the next 4-6 weeks. Additional cards can be requested later in the process. If no cards are required at this time, please enter 0.Send the Initial ClinCard Order to:* Requestor Principal Investigator Orders will be delivered through Central Stores.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.