Clinical Reserach Recruitment Consultation Intake Form

Contact Information

Person Requesting*

First & Last Name of person completing this form.

Email Address*

Phone Number*

Phone

PI First Name*

Principal Investigator First Name

PI Last Name*

Principal Investigator First Name

Department*

If not listed in dropdown, please enter your department name.

Select or enter value

Project Information

Study Title*

Enter the short name, acronym, or nickname for your study.

Funding Source*

What is the funding source(s) for this study? Choose from the options below or type in your answer.

Select or enter value

NCT Number (ClinicalTrials.gov)*

The NCT number starts with "NCT" followed by 8 numeric digits (e.g., NCT12345678).

Enter "Unsure" if you don't know the ClinicalTrials.gov registration status.
Enter "N/A" if not required to be registered on ClinicalTrials.gov.

IRB Number*

Please enter your IRB # or tell us the IRB status (not yet submitted, etc.)

IRB of Record**

Are you using UCD IRB or relying on another IRB for this study? Please select the IRB from the dropdown, or type in if not listed.

Select or enter value

IRB Status*

Tell us what phase of recruitment you are in.

Pre-Approval (Not yet submitted to IRB)
IRB Approval In Progress (IRB submission started, but not yet approved)
IRB-Approved, Start-Up Phase (IRB approval received, but still finalizing logistics/funding/other approvals)
IRB-Approved, Recruitment Attempted (Study has begun but need additional recruitment support/methods)

Select or enter value

Project Urgency*

Definitions:

Exploratory (Study design/planning phase)
Just Starting (Ready to recruit/Recruiting)
Desperate (Funding ends in 3-6 months)

Select or enter value

Contract Status

Please check the box if you have a finalized contract & budget in place for this project.

Leave blank if contract/budget is pending or N/A.

Funding Status

Please check the box if you currently have funding secured for this project.

Leave blank if funding is pending or N/A.

Enrollment Goal*

How many participants are you recruiting?

Total Enrolled*

How many participants have you enrolled to date?

Reason for Consultation*

In a few words, please tell us why you are requesting a consultation with us.

Studypages Link

Please enter the url (webpage link) to your StudyPage (if available)

File Upload*

Please attach any relevant documents (Current Protocol, Informed Consent Form(s), Recruitment Materials, Survey Questions, etc.). You can attach multiple documents here.

Drag and drop files here or

Send me a copy of my responses

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