CHRI Services Intake Form

CHRI Services Intake Form

Please review prior to submission:

Completion of this form is the first step for CHRI members to secure research services including pre-award (budgets, grant submission), biostatistician assistance, scientific writer consultation, and research coordinator support from the Pediatric Research Office.

If you are not yet a CHRI member, sign up here to gain access to our many services!

Accurate completion of this form helps facilitate the timely deployment of the correct team member(s), as well as efficient internal tracking of CHRI projects. Thank you for your assistance!

We are experiencing a high volume of support requests. As a result, there may be a delay before staff are available to take on additional projects. We appreciate your patience.

What is the title of the project?*

Please enter the lead Principal Investigator's (PI's) first name*

Please enter the lead PI's last name.*

Please enter the lead PI's preferred email address*

This email will be our primary method of contact; please list an email you regularly review!

Are you the lead PI for this project?*

If you are filling this out on behalf of the PI, select "No"

Yes

What is your name?*

What is your email?*

Which CHRI service(s) are you requesting for this project?*

Pre-Award (i.e grant submission, budget, new subaward, etc)

Biostatistics support (i.e. power calculation, data analysis, etc)

Scientific Writer consultation (i.e manuscripts, abstracts, aims page, etc)

Pediatric Research Office (PRO) services (i.e. coordinator support, industry sponsored trials, etc)

What do you need Biostatistician assistance with?

Study/Protocol Design

Power Calculation (i.e. for a grant or IRB)

Data Management Consult

Data Analysis (i.e for an abstract or manuscript)

Other Statistical Services

What type of document do you need Scientific Writing assistance with?*

Abstract

Manuscript

Grant

What is the submission deadline?*

Please provide the specific due date provided by the agency, sponsor, conference, etc.

Deadline provided is within three weeks

CHRI aims to provide prompt research support services, but requires at least three weeks' notice of submission deadlines (i.e. to SPA or a journal). Please note that completion of your request by the deadline provided may not be feasible given other obligations.

Check to acknowlege you have reviewed the above notice regarding CHRI's three-week's notice policy:*

Please provide a direct link (URL) to the funding announcement/RFA:*

Which best describes the sponsor of this funding opportunity?*

Please describe the sponsor of this grant:*

Is this grant a subaward from another institution who is receiving funding from the prime sponsor?*

Yes

Please provide the name of the institution:*

What study tasks are you requesting PRO assistance with?*

Pre-Study Consultation

IRB/Regulatory Assistance

Patient Screening, Enrollment, and/or Study Visits

Data Entry, Source Document Development

Industry Trial Budget or Billing Grid

Contracts/DUAs/Legal

Is this a clinical / human subjects study?*

Yes

Do you have IRB approval?

Yes

What is the IRB number?*

Which of the following best describe the study?*

Where will the study take place?*

Children's Nebraska

Nebraska Medicine

A different location

Please provide any additional details about your project and the CHRI services you are requesting below:

Please upload any and all documents related to this project (study protocol, budget, emails, etc)

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.