This form is used in matching the client’s needs with the proper statistical expert in order to ensure the best possible services. This form must be returned to the Division of Biostatistics before an appointment can be scheduled. Date: Name: (Last/First): Title: Faculty Staff Resident/Fellow Grad Student Medical Student Other:
Department: Campus Mailing Address: (Building) (Room Number) If non-campus address, include street, city and zip code: Phone (Office): Pager #: Fax (Office): E-Mail: Title of Research Project:
Is this a grant preparation project: Yes No
Type of Research: Clinical Research Translational Research
Other:
Stage of Research: Design (no data yet): Grant Preparation: Data Collection: Analysis (data collected): Peer Review: Do you have IRB Approval? Yes No Institution and IRB Approval Number: If design is completed, was a statistician consulted for design? Yes No If yes, provide name of statistician: Indicate important time deadlines: Results likely will be published as: Journal Abstract Give brief description of scientific background for study. List briefly, the specific aims of the study. What data is to be used to achieve these aims? Give brief description of data you have collected: Signature: (Please Type in your full name as signature)