CERB Intake Form
CERB Support Intake Form. Completion of this form will help facilitate your request.
1. Project Name:(Please provide both the full study title (descriptive)) and the working study title.
*
2. PI Contact Information
Name:
*
First Name
Last Name
Email:
*
example@example.com
Institution Affiliation:
Department:
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Project Contact Name:
*
First Name
Last Name
Project Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Project Contact Email:
*
example@example.com
3. What is the category of your proposal/project?
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Special Projects
Full RFA
Other (Please Specify Below)
Specify Your Other Category
4. What is the status of your proposal/project?
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Pre-submission/writing
Pre-IRB Approval
Submitted Unfunded
Funded/Pre-Implementation
Implemented
5. What level of support are you seeking, from the CERB? (Check all that apply)
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Community Ethics review and critique of proposal
Letter of Endorsement
Suggestions for enhancing the community engagement component
Serving as the project's Community Advisory Board
Other (Please Specify Below)
Specify Your Other Level of Support
6. Project Abstract:
*
7. Project Abstract File Upload:
*
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8. Full Research Proposal:
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9. Full Research Proposal:
*
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10. The requested support is needed by:
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-
Month
-
Day
Year
Date
11. Referred By:
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Academic Partner
Community Member
CERB Member
SUBMIT YOUR PROJECT: We look forward to collaborting with you to empower our community!
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