Key
bold item is added or changed
strike through item will be removed, but currently exists
blue text is the type of form field used online, and also says something about the type of db field
Contact Information
First name: text field: single line
Last name: text field: single line
Organization (i.e., C/I/O): text field: single line
Primary Phone: text field: single line
Primary E-Mail: text field: single line
Receive notifications? Checkbox
Secondary First name: text field: single line
Secondary Last name: text field: single line
Secondary Organization (i.e., C/I/O): text field: single line
Secondary Phone: text field: single line
Secondary E-Mail: text field: single line
Receive notifications? Checkbox
Please list names and email addresses of your team members who will require access to the requested lab resources:
Group name text field: single line {this field is admin only]
Name Email Username {this field is admin only]
text field: single line text field: single line text field: single line {this field is admin only]
text field: single line text field: single line text field: single line {this field is admin only]
text field: single line text field: single line text field: single line {this field is admin only]
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IIU Services Requested
Would you like to use 1 or more virtual computers (VM's) running in the Public Health Informatics Research Cloud? Radio buttons: Yes No
Would you like to use the Physical Collaboration space in 2500 Century Center?: Radio buttons: Yes No
If yes, how many simultaneous physical workstations (lab seats) do you require at one time? (spin box - max 18)
Would you like to have a consultation session with IIU's Innovation team?: Radio buttons: Yes No
If yes, please describe what you would like to discuss: text box: multi-line
Would you like access to test out specific hardware (e.g., mobile device)?: Radio buttons: Yes No
Project Details
Project Title/Name: text field: single line
Requested Start Date: text field: auto calendar
Requested End Date: text field: auto calendar
Project Type: 3-item drop-down list {this field is admin only] Choices: Prototype, Evaluation, Hybrid
Project Use: 3-item drop-down list {this field is admin only] Choices: Internal, External, Collaborative
We can best help you meet your needs if we have a general understanding of your project. Please help us frame your project by addressing the following questions. Even if you are only requesting use of the physical laboratory space, a project summary will allow us to potentially leverage other R&D technology initiatives in working with you.
Project Summary: text box: multi-line
Project Goals: text box: multi-line
Project Success Criteria: text box: multi-line
Approved project Start Date: text field: auto calendar {this field is admin only]
Approved project End Date: text field: auto calendar {this field is admin only]
Project Stakeholders:
Who are the stakeholders (users/actors) in your proposed engagement? Please list key technology users, data suppliers, report recipients, as well as any applicable governing guidelines (e.g., HIPAA).
Stakeholder*# Role**
text field: single line text field: single line
text field: single line text field: single line
text field: single line text field: single line
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*Organization, C/I/O, user group, individual, etc. **e.g., User, data supplier, report recipient, governing body. #Please note that you can choose more than one role per stakeholder.
Technology Requirements
The Lab has defined a set of core technology standards which can be quickly installed as a default (i.e., not otherwise specified). Please modify as needed for your specific project requirements. Please list specific software needed in the Notes section.
Computing Resources
Resource Type 1: Virtual Computer (VM)
VM Configuration: Drop-down select (LIST PROVIDED BY DALE) - example: Windows7 desktop, Windows Server 2008, SQL Server, CentOS, etc.
Notes: text box: multi-line
VM name: text field: single line {this field is admin only]
Internal Notes: text box: multi-line {this field is admin only]
Proxy from: text field: single line {this field is admin only]
Proxy to: text field: single line {this field is admin only]
Add More: button: will add another set of fields like above
VM Request Details:
Will any of your requested VMs run services which will need external lab access (e.g., a publicly available web site)? Radio buttons: Yes No
If yes, please provide details: text box: multi-line
Will any of your VMs connect to non-production systems/databases OUTSIDE CDC? Radial buttons: Yes No
If yes, please provide details: text box: multi-line
Will any of your VMs connect to non-production systems/databases INSIDE CDC? Radial buttons: Yes No
If yes, please provide details: text box: multi-line
Resource Type 2: Non-VM (mobile device, etc.)
Device: text field: single line
Notes: text box: multi-line
Add More: button: will add another set of fields like above
Device Serial #/Device ID: text field: auto calendar, default to project start date {this field is admin only]
Data Resources:
If your project involves the use / testing of data (synthetic data, publicly available, etc.,) please describe the following:
What is/are the primary sources of data, if any, for the proposed technology? Please note that all data sets must be examined (e.g., for privacy & security) prior to loading into the lab environment. The lab can provide synthetic data if necessary.
text box: multi-line
Will your project require access to any third-party websites and/or applications? Radial buttons: Yes No
If yes, please provide details below:
Website Description
text field: single line text field: single line
text field: single line text field: single line
text field: single line text field: single line
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Please feel free to provide any additional information regarding your technology needs below. text box: multi-line
Project Status: 9-item drop-down list {this field is admin only] Choices: On Hold, Awaiting Submission, Under Review, Submitted, Rejected, Submitter Revising, Approved, Discontinued, Completed
Project Status Notes: text box: multi-line {this field is admin only]
Infrastructure Status: 9-item drop-down list {this field is admin only] Ready, To Set Up, On Hold, Setting Up, Modifying, To Take Down, Taking Down, Removed, Archived
Infrastructure Status Notes: text box: multi-line {this field is admin only]
Outcome / Summary / General Notes: text box: multi-line {this field is admin only]
Please confirm that all the entered information is accurate. Click "Submit" when ready.
Once you have submitted your information, if you need to make changes, please contact the R&D Lab at informaticslab@cdc.gov
Submit button
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