Proposal Summary Form
Request for Financial and/or Technology Support for Investigator Initiated Study (IIS)
Form Submission by:
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First Name
Last Name
Suffix
Email
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example@example.com
Affiliate Institution(s)
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Title of Proposed Project
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For referral purposes only
Study Rationale
Please describe your proposed study's rationale and how it relates to clinical and/or economic outcomes.
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Previous Work
Please indicate any work/findings by any proposed investigator (including yourself) in the area of proposed research.
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Primary and Secondary Objective(s)
Please indicate the one main objective on which your proposed study would focus.
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Please indicate any secondary objective(s), if applicable, for your proposed study.
Study Design
Please detail the design of your proposed study.
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i.e. Open label, double blind, randomized, etc...
Expected number of patients or subjects to be studied, including justification of sample size?
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Please include both the total number, and number in each arm, if applicable.
Population to be examined?
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i.e. Inclusion/Exclusion criteria for proposed study.
Estimated study start date?
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Month
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Day
Year
To identify approximate study duration.
Estimated study end date?
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Month
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Day
Year
To identify approximate study duration.
If study is to be conducted in human subjects, please estimate the date of first subject visit.
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Month
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Day
Year
Date
If study is to be conducted in human subjects, please estimate the date of last subject visit.
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Month
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Day
Year
Date
Primary and Secondary Measure(s)
Please indicate the one primary measure that will be used to substantiate the primary study objective.
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Please indicate any secondary measure(s), if applicable.
Anticipated Findings
Please describe the anticipated results from your proposed research.
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Publication Plan
Number of manuscripts planned?
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Principal author of the primary publication?
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First Name
Last Name
Suffix
Forecast date for submission of primary manuscript?
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Month
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Day
Year
Date
Choice journal for publication?
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Additional Information
Please provide any additional information that you feel the committee should be aware of in the evaluation of your request.
Please submit the completed form by clicking the "Submit" button below.
Please note - additional forms/information may be required, including, but not limited to: Part II: Proposed Budget, CV for Principal Investigator, etc.
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