CCORDA online request

Date:

Name of Principal Investigator:

Appointment type: Faculty
Staff
Resident/Fellow
Post-Doc
Grad/Medical Student
Other

If student/resident/fellow
Name of Faculty Mentor:

Department/Division:

E-Mail:

Telephone:

Indicate important time deadlines (abstracts, etc.):

Reason for deadline: grant submission
abstract
presentation
manuscript
other

IRB approval: yes
no
pending

If "yes", IRB approval number:

Brief description of the project:

1) Project title:

2) Cancer related: yes
no

3) Type of support requested: Research design/development
Database development
Data acquisition and management
Clinical research ethics
Data analysis/statistical support
Research with underserved populations
Community-Based Participatory Research

4) Brief goals and description of the project

Important things to bring to the first meeting:

Your research hypothesis.

Your data (if available -- on a disk or other portable media if electronic version is available). A printed example of your data is also useful for discussion. Please make sure you have IRB approval. Personal identifying information should be removed.

Relevant papers from the literature.

Your written research proposal or draft of your manuscript if available.

Breakthroughs for life.

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Date:
	Name of Principal Investigator:
	Appointment type:	Faculty Staff Resident/Fellow Post-Doc Grad/Medical Student Other
	If student/resident/fellow Name of Faculty Mentor:
	Department/Division:
	E-Mail:
	Telephone:
	Indicate important time deadlines (abstracts, etc.):
	Reason for deadline:	grant submission abstract presentation manuscript other
	IRB approval:	yes no pending
	If "yes", IRB approval number:

	1) Project title:
	2) Cancer related:	yes no
	3) Type of support requested:	Research design/development Database development Data acquisition and management Clinical research ethics Data analysis/statistical support Research with underserved populations Community-Based Participatory Research