Date of initial contact:
Email Address of Person Completing Form:
Project Title:
Primary Investigator:
Department:
Phone:
Email:
Center Affiliation (if applicable) Indicate All that Apply:
Center on Aging
Center for Biostatistics and Advanced Informatics
Hoglund Brain Imaging Center
Center for Environmental & Occupational Health
Center for Reproductive Sciences
Developmental Disabilities Center
Mental Retardation and Developmental Disability Research Center
Kansas Masonic Cancer Research Institute
Kidney Institute
General Clinical Research Center
Co Investigator(s):
Cancer or Cancer related:
If Yes, please indicate:
If Other, specify:
If No, specify:
Primary Disease Site:
Funding:
Type of Center support requested:
(Indicate All that Apply)
Study Design/Development
Form Development
Database Development
Data Management
Data Analysis/Statistical Support
Quality Assurance/Monitoring
Other:
Stage of Project: (MUST indicate one)
Development Phase (has not been submitted and/or received Institutional Approvals)
Human Subjects Certification (including Exempt studies)
IRB Approval #:
Date:
Vertebrate Animals
IACUC Approval #:
Date:
Please list any CBAI staff currently associated with this project:
Comments, Description or Other Information:
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