Date

Requestor/PI*

Department/Division*

Email Address*

Phone Number*

Project Title *

Project Summary*
(please also attached protocol draft):

Study Population*
(including ages, dx, sex; include estimated number of patients and number of visits per month if known):

Study Timeline*
(e.g. January 2019 - December 2021):

Funding Mechanism *
SponsorNIH grantFoundation GrantOther

Requested Services:*
Test administration (include the full name of test and frequency of administration-e.g. Mullen at Baseline; Vineland at Baseline and Week 26 visit and whether an HNBCS psychologist and/or trained research assistant is required to conduct the testing):

Testing Supplies (e.g. kits, protocols, scoring software needed)
Provided by RequestorRequire Purchase

Research Location*
(e.g. 1295 Boylston, CTSU, Other-please specify):

Research Report Generation (Will this be needed?)*
The HNBCS can supply a research report for each participant if desired. Research reports are reviewed and signed-off by a HNBCS psychologist and sent by the PI's study team to the participant.
YesNo

Questions/Comments