The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

rVpUNNYR3cTiQX32ovQGUm2eEffpD

Penn Implementation Science Center (PISCE)@LDI Consultation Meeting Request

Thank you for your interest in meeting with the Penn Implementation Science Center (PISCE@LDI)! We look forward to hearing your ideas.

What to expect: Consultations may involve a brief initial meeting with a member of the PISCE@LDI staff to talk about your goals and receive initial feedback and relevant D&I resources. Depending on the type of request, the PISCE@LDI staff member may refer you to a member of the leadership team for a 30-minute meeting in which you can go into more depth about your questions. If you have any questions, please contact isabelle.kaminer@pennmedicine.upenn.edu.

Name

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Email Address

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Affiliation

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School of Arts & Science

The Wharton School

Annenberg School for Communication

School of Dental Medicine

Stuart Weitzman School of Design

Graduate School of Education

School of Engineering and Applied Science

Penn Carey Law

Perelman School of Medicine

School of Nursing

School of Social Policy & Practice

School of Veterinary Medicine

Children's Hospital of Philadelphia

Other (specify):

* must provide value

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Position

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Other (specify):

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Are you a member of PISCE@LDI?

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If you would like to join, sign up to become a member here: https://redcap.med.upenn.edu/surveys/?s=HR87F9EDYR

What is your current level of experience with dissemination and implementation (D&I) research?

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Novice (no previous experience with D&I)

Beginner (some exposure to D&I)

Intermediate (led a study with some implementation science-related aims)

Expert (led R01 grant-level projects in implementation science)

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Please specify your other experience level

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Primary Reason for Meeting

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Please specify the funding mechanism:

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Other (specify):

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Please briefly tell us about your consultation needs.

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If you are requesting a meeting for a research project, what is the status of the project?

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Please specify the other status of your project

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What are the D&I questions you would like to answer?

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What is your timeframe? (please list any specific deadlines)

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Is there anything else that you think is important for us to know about your consultation request?

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.