COINS New Study Form
Principal Investigator Full Name
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First Name
Last Name
Principal Investigator E-mail Address
*
example@example.com
Study Coordinator Full Name
First Name
Last Name
Study Coordinator E-mail Address
example@example.com
Request Study Name - What would you like your COINS Study name to be (12 characters or less)?
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IRB Number (from IRB Approval Letter)
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IRB Title (Please copy full study title directly from IRB Approval Letter)
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IRB Approval Date (From IRB Approval Letter MM/DD/YYYY)
*
Please upload a copy of the IRB Approval Letter and stamped 'Approved' consent form.
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Study Information
Estimated Study Start Date (Date that you would like to enroll your first participant. Format MM/DD/YYYY).
Estimated Study End Date (Date that you would expect to close your study with the IRB. Format MM/DD/YYYY).
Total Number of Study Participants (Number of URSIs needed for this study).
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Additional Information
Funding Source
Internal Funding
CABI Seed Grant
External Funding
Funding Account Number/Speedtype
Identify all IRB-approved study personnel who should have study access.
Subject Types (Please enter in a list the different subject groups for your study -- Control, Patient, etc.).
Study Visits (Please enter in a list the different study visits for your study. Please also indicate the Time from Baseline for each visit (e.g., Baseline (0 days), Visit 1 (3 months), Visit 2 (6 months), etc.).
Expiration Warning Email Notification List (Please list the email addresses for the study staff that you would like to receive Email notifications when this study is scheduled to expire). Format: example1@hotmail.org, example2@gmail.com, etc.
Primary Research Area
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Addiction
Creativity
Forensics and Social Cognitivity Research
Neurodevelopment
Neuroinformatics
Neurosystems for National Security
Pain
Psychosis
PTSD
TBI
Other
Modalities You Plan to Use
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MRI
EEG
Other
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