HSIR Project Request Form

Title  *PI and Unit Affiliation  *Other Investigators and Affiliations Estimated Cost  *Topic Area(s)/Keyword(s)  *


What is the object of the proposed pilot and the significance of the work.


- What is the problem statement and/or hypothesis(s)?
- What standards of practice and/or research does this build from (what is the previous work in this space)?
- State the description of need.

Work Description

What is the proposed work plan?

- Where is the pilot work taking place?
- What are the activities?
- What is the timeline?
- What is the method(s)? (e.g. are you going to collect patient outcome data, interview patients, review retrospective chart data, assess usability of a tool, measure impact on workflow, combination of various methods)?

Data & Evaluation

- What data do you plan to collect? How are you planning on collecting the data?
- What is the evaluation plan?

Proposal Products

Is there a potential for publishing a paper, presenting at an internal or external conference or meeting, the development of a demo, etc.?