Stanford Medicine Community Engagement Assistance Intake Form

Attention: If you are seeking assistance involving the participation of Stanford patients in research studies, please skip this form and visit Spectrum's Research Participant Engagement Program.

For all other requests, please fill out this form in its entirety. Thank you!

First Name*

Last Name*

Department/Organization*

Title/Position/Role*

Which role best describes you?*

Select or enter value

Email Address*

Contact Number

What is the nature of your request? (Select all that apply)*

Community-engaged research or evaluation project

Seeking support for research involving diverse populations

Community-engaged education activity (e.g. looking to pair students/learners with community partners)

Service-oriented activity requiring engagement between Stanford and community partners

Engagement request (e.g. speaker/guest lecturer) for one-time or recurring event?

Other

Are you seeking assistance with a grant application?*

We respectfully request a lead time of 4-6 weeks lead time before a proposal is due. Thank you.

Select or enter value

If this is for a deadline driven proposal/grant, when is it due?

If known, which office are you hoping to reach with your request?*

You can learn more about each office by clicking on the links to the left of this form.

If you are not sure about which office to contact, please select Stanford Medicine Office of Community Engagement (OCE).

Stanford Medicine Office of Community Engagement (OCE)

Stanford Cancer Institute Office of Cancer Health Equity and Community Engagement (CHECE)

Department of Medicine, Community Partnership Program

Stanford Maternal Child Health Research Institute (MCHRI) Office of Community Engaged Research

Department of Pediatrics Office of Child Health Equity (OCHE)

Other

If other, please explain:

Is your project/inquiry cancer-related?*

Select or enter value

Please provide more information about your request. If this is a research project, please provide details, including purpose, aims, and research question(s)*

Please be as specific and concise as possible. Provide any background information on the issue for which TA is being requested.

What is the current project status*

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If "other," please explain.

Goals and Outcomes*

Please describe the goals and outcomes you would like to achieve as a result of this technical assistance.

How did you hear about our Community Engagement Technical Assistance service?*

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Other

Please explain.

Additional Notes and Information:

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