RESEARCH
CENTERS IN MINORITY INSTITUTIONS
TRANSLATIONAL RESEARCH NETWORK
REQUEST A COST PROPOSAL
Contact Information
Submit Date:
(mm/dd/yyyy)
Tracking Number:
Requestor's Name:
Requestor's Title:
Principal Investigator:
PI eMail Address:
Institution/Organization:
Address:
City:
State:
Zip:
Phone Number:
(777-888-9999)
eMail Address:
Administrative Assistant Contact Information
Admin Assistant Name:
Admin Assistant eMail:
Admin Assistant Phone:
(777-888-9999)
Project Details
Copy of Proposal:
Clinical/Community-Based Participatory Research: (select all that apply)
Community-based Participatory Research
Pilot
Type:
Investigator-initiated
Industry-initiated
Genetics
Other
Specify:
Epidemiology
Basic Science: (select all that apply)
Biochemistry
Genomics
Microbiology
Animal Studies
Immunology
Other
Proteomics
Specify:
Study Details
Identify Study Phase:
Phase I
Phase II
Phase III
Phase IV
Other
Specify:
Intervention Study?
YES
NO
Randomization Required?
YES
NO
Control Group Used?
YES
NO
Scope of Work: (select all that apply)
Protocol Review
Statistical Services
Proposal Review
Web Development
Clinical Data Services
Web-based Course Development
Data Warehousing/Repository Management
Multimedia Services
Informatics
Other
specify:
Scope Comments: