Research consultation form:
Basic steps to take prior to your first meeting with your colleague and/or mentor
All research information on this form is confidential (see our privacy policy below)
 Your Name:
 Best Phone Number:
  Email Address:
NOTE: After completing this form, you will have an opportunity to send it via email to your colleague and/or research mentor. This will be done at the end of the process. I recommend that you write your answers down with pencil and paper first, and afterwards type them in here or from a word processor. (Alternatively, you can print this form and fax to the appropriate person)

Valuable link: Ed Panacek's instructional videos on basic research: Click Here to View

 Draft Research Question - It's OK to be "broad" here
Literature search completed (List 10 important references.)
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 Focused Research Question (here is where you try to get as specific as possible):
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Research Hypothesis:
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Types of variables in your study
An independent variable is usually the variable you (the researcher) control; example: which dose of an antibiotic is given would be an independent variable, whereas cure from pneumonia would be a dependent variable.
Independent Variable(s):
Dependent Variable(s):
Confounding or extraneous Variables (list at least 3)
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Proposed Study Designs (list at least 2 that could be used)
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Study 1:

Study 2:

Other Designs:

Power Calculation
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1. What is the percent or amount of difference in the primary outcome measure that would be clinically significant to detect in your study?
Sometimes related research can help with this estimate:

2. Please indicate here if you will need assistance with study size calculation for your study.

If you already know, how many study subjects will you need?
List inclusion and exclusion criteria for your study:
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Inclusion Criteria Exclusion Criteria
1: 1:
2: 2:
3: 3:
4: 4:
5: 5:
6: 6:
7: 7:
NOTE: the following questions are of a somewhat more technical nature. You will get better at doing this as you gain experience with clinical research. Your colleague and/or mentor will likely add, modify or change these, but it is important that you think about these before your meeting.
Study Measurements:
Proposed Study Measurements (e.g. serum drug level, time since ingestion Qtc) Category of the data(nominal, ordinal, continuous, etc.)
1: 1:
2: 2:
3: 3:
4: 4:
1: 1:
2: 2:
3: 3:
4: 4:
Please select the primary outcome measurement for the study above:
List an appropriate statistical test for each of the measurements listed above.




FINAL STEP: Send this to your colleague and/or mentor.
Please note: you do not have to send a perfect study design. This form is intended to start you thinking about the necessary steps to design a research study.
Enter the email of your colleague and/or mentor:
(If you are emailing to more than one person, please separate email addresses with a comma.)

Additional Comments:
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Daniel Keyes, MD, MPH (form conception and design)
Associate Chair, Academic Affairs, Emergency Medicine, SJMHS Ann Arbor, MI

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