Date

Name of person making request*

PI if different from requestor*

Email address*

Phone number*

Project title *

Is this PI's first clinical trial or research project?*
YesNo

Will this project be filing an IND/IDE with the FDA?*
YesNoProject is exempt

Type of services requested (check all that apply)*
Clinical Research and Regulatory Affairs ServiceHuman Neurobehavioral Core ServicesRepository Core for Neurological Disorders

Clinical Research and Regulatory Affairs Service (check all that apply)
Project consultationProtocol development including trial designRepository Core for Neurological DisordersRegulatory guidanceProject managementStudy staff training/supportPatient recruitment/Registry

Human Neurobehavioral Core Services (check all that apply)
Project consultationPerforming direct neurobehavioral assessments

What type of project is this?*
Clinical drug trialClinical device trialBiomarker studyBehavioral interventionOutcome studyNatural History StudiesOther: please specify

Funding Source (check all that apply) *
Industry SponsoredInvestigator Initiated/BCHGrant Supported (Foundation/GovernmentDivision/Departmental FundsOther

Funding Status*
CommittedPending

Additional Information