Clinical Reserach Recruitment Consultation Intake Form

First & Last Name of person completing this form.

Principal Investigator First Name

Principal Investigator First Name

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

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

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

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.

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

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.

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)

Definitions:

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

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.

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

Leave blank if funding is pending or N/A.

How many participants are you recruiting?

How many participants have you enrolled to date?

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

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

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