ࡱ>  _bjbj . /((kkkkk85AB|).r))))eB<((((((($*-(k]a(kk))4r)c%c%c%Xk)k)(c%(c%c%c%)|c%()0)c%0.W 40.c%0.kc%<c%((#)0.( 1: Department of Preventive Medicine/UTHSC Consultation or Collaboration Request Form In accordance with the policy of the Department of Preventive Medicine, please complete the information below to request services. Please be sure to attach a copy of your IRB/IACUC/IBC approval and a copy of your approved protocol (if applicable). Requested by: FORMTEXT      Date of request: FORMTEXT      Phone: FORMTEXT      Department: FORMTEXT      Email: FORMTEXT      Institution: FORMTEXT      Project Title: FORMTEXT      Short Title: FORMTEXT << Preferred short title, if any >>PI: FORMTEXT      PI s Department: FORMTEXT      PI s Email: FORMTEXT      PI s Institution: FORMTEXT       Please note: We will inform the PI about our contribution to the project. Indicate the role requested: FORMCHECKBOX Consultation FORMCHECKBOX Collaboration Indicate the type of services needed: (Please check all that apply) FORMCHECKBOX Study Design FORMCHECKBOX Statistical Analysis FORMCHECKBOX Grant Review FORMCHECKBOX Manuscript Review FORMCHECKBOX Grant Writing FORMCHECKBOX Manuscript Writing FORMCHECKBOX Informatics FORMCHECKBOX Other:  FORMTEXT << Please describe >> State your research question:  FORMTEXT << Please be specific >> Purpose of this request:  FORMTEXT << How do you intend to use the result of our effort? >> Is a grant associated with this project? FORMCHECKBOX No FORMCHECKBOX Yes, details: FORMTEXT       Is a particular program or initiative associated with this project? FORMCHECKBOX CTSI (  HYPERLINK "https://ctsi.utmem.edu/" https://ctsi.utmem.edu/ ) FORMCHECKBOX Other, FORMTEXT <> FORMCHECKBOX No program or initiative is associated with this project. Will any of the following be prepared as a result of this project? (Please check all that apply) FORMCHECKBOX Abstract FORMCHECKBOX Manuscript FORMCHECKBOX Grant application IRB/IACUC/IBC IRB: Institutional Review Board (  HYPERLINK "http://www.utmem.edu/research/research_compliance/IRB/" http://www.utmem.edu/research/research_compliance/IRB/ ) IACUC: Institutional Animal Care and Use Committee (  HYPERLINK "http://www.utmem.edu/research/research_compliance/IACUC/" http://www.utmem.edu/research/research_compliance/IACUC/ ) IBC: Institutional Biosafety Committee (  HYPERLINK "http://www.utmem.edu/research/research_compliance/IBC/" http://www.utmem.edu/research/research_compliance/IBC/ ) Has the project been reviewed by an IRB/IACUC/IBC?  FORMCHECKBOX No FORMCHECKBOX Services are being requested in preparation for submission to the IRB/IACUC/IBC FORMCHECKBOX Does not need approvalExplain: FORMTEXT       FORMCHECKBOX Yes (please provide a copy of the approval) FORMCHECKBOX UTHSC s IRBIRB#: FORMTEXT       FORMCHECKBOX UTHSC s IACUCIACUC#: FORMTEXT       FORMCHECKBOX UTHSC s IBCIBC#: FORMTEXT       FORMCHECKBOX Other institution s IRB/IACUC/IBCDetails:!'(7ERST     * ; L M N Z \ ] g h ĹĹīĐ҅|paVD#jh h*aCJUaJh h*aCJaJjh h*aCJUaJh h#25CJaJhQz5CJaJh]jhkCJaJh(ho(5CJaJh(h56>*CJaJh(h5>*CJaJh8v5>*CJaJh(h'5>*CJaJh(h'5CJaJ hEw 5 hT05 hL, 5 h5 ho(5hT0hT05(STM N \  0 X $Ifgd?[ $Ifgd $$Ifa$gd@l#gdT0$a$gd +^$a$gdT0 h  . 0 2 F H J T V X Z d h j ~ ĸЃtiWtBtit(jh ho(CJUaJmHnHu#jh ho(CJUaJh ho(CJaJjh ho(CJUaJh ho(5CJaJ"jhQzCJUaJmHnHujthQzCJUaJhQzCJaJjhQzCJUaJh h#25CJaJhQz5CJaJh h#2CJaJjhCJUaJjh h*aCJUaJX Z h }qhqh $Ifgd?[ $$Ifa$gd@l#kd$$Ifl4\bH," > t644 laf4ytr`     " $ 8 Կr]RF>h CJaJjh CJUaJh h#2CJaJ(jh h*aCJUaJmHnHu#jPh h*aCJUaJh h*aCJaJjh h*aCJUaJh h#25CJaJhQz5CJaJh ho(5CJaJ(jh ho(CJUaJmHnHujh ho(CJUaJ#jh ho(CJUaJh ho(CJaJ  " J }qhqh $Ifgd?[ $$Ifa$gd@l#kd$$Ifl4\bH," > t644 laf4ytr`8 : < F H J L j l ǻwlcZNB:hp$CJaJjhp$CJUaJh hp$5CJaJhp$5CJaJh:T5CJaJh ho(CJaJjhCJUaJ#jh hHCJUaJh hHCJaJjh hHCJUaJh ho(5CJaJh h#25CJaJh h#2CJaJ"jh CJUaJmHnHujh CJUaJjh CJUaJJ L j }qh $Ifgd $$Ifa$gd@l#kd8$$Ifl4\bH," > t644 laf4ytr`   2[kd$$Ifl40b," t644 laf4ytr` $Ifgd $$Ifa$gd@l#[kdk$$Ifl40b," t644 laf4ytr`        2 4 6 @ B D N b f h | ~ j_VDj_#jh h*aCJUaJhQz5CJaJh h#2CJaJ(jh h*aCJUaJmHnHu#j-h h*aCJUaJh h*aCJaJjh h*aCJUaJh h#25CJaJh 5CJaJh hp$5CJaJh hp$CJaJhp$CJaJmHnHujhp$CJUaJjhp$CJUaJ  D f  hkd$$Ifl4\bH," > t644 laf4ytr` $Ifgd?[ $$Ifa$gdQz      : xl`RFRh ho(6CJaJh ho(56CJaJh h#25CJaJh hQz5CJaJ"jhCJUaJmHnHujH hCJUaJhCJaJjhCJUaJhS5CJaJh hQzCJaJ"jhQzCJUaJmHnHujhQzCJUaJhQzCJaJjhQzCJUaJhQz5CJaJ  }xpxxgSg$:$If^:`a$gdQ $IfgdT0$a$gdsUgdT0kd $$Ifl4\bH," > t644 laf4ytr`   '()9:;bj޹ޥޜ{jVjJjh ht.5CJaJ&jc h h5CJUaJ jh h5CJUaJh:5CJaJh h5CJaJh h, 5CJaJh5CJaJ&j h h?[5CJUaJ&j{ h h?[5CJUaJ jh h?[5CJUaJh h?[5CJaJh h !5CJaJh#25CJaJ*89:;ZUUL $Ifgd:gdT0kdc $$Iflr x H4"  t"644 laytQ $IfgdT0 $$Ifa$gdQ $Ifgd"= $$Ifa$gd"=Hkd $$Ifl4,"" t644 laf4ytj(   )*+9:;<NPQƺϦϺϒϺ~ϺjϺ\jht75CJUaJ&jnh h5CJUaJ&jh h5CJUaJ&jh h5CJUaJ&jK h h5CJUaJh ht.5CJaJhf5CJaJh h5CJaJ jh h5CJUaJ&j h h5CJUaJ# *<OWKBKBKB $Ifgd"= $$Ifa$gd"=kd $$Ifl4ֈ \ ,".Z @H R6 t644 laf4ytj(OPbnWKBKB $Ifgd"= $$Ifa$gd"=kd$$Ifl4ֈ \ ,".Z @H R6 t644 laf4ytj(Q_`abmno}~˺˦˗zj^RCjh hoCJUaJh hy=5CJaJh ho5CJaJh ht7CJaJmHnHu#jh ht7CJUaJh ht7CJaJjh ht7CJUaJ&jh ht75CJUaJ jh ht75CJUaJh ht75CJaJjht75CJUaJ jht75CJUaJht75CJaJ}xxo $IfgdT0gdT0kd1$$Ifl4\ \ ,".Z @ t644 laf4ytj(246}naVMDhnn5CJaJhf5CJaJh h&fCJaJh&fCJaJmHnHujh&fCJUaJh&fCJaJjh&fCJUaJh h&f5CJaJh5CJaJh 5CJaJh&f5CJaJh ho5CJaJh hoCJaJmHnHujh hoCJUaJ#jh hoCJUaJh hoCJaJ $Ifgdd gd&flkdr$$Ifl,"" t0644 layt@l#&,.~~~ $Ifgdd $Ifgdnngd&fjkd$$Ifl ,"" t0644 layt "$&*.024PRTV\`prt"ٿٷ󫿜ٿٿيuٷlchnn5CJaJhf5CJaJ(jh(4hnnCJUaJmHnHu#jh(4hnnCJUaJjohnnCJUaJjhnnCJUaJh@l#hnn5hnnCJaJ#jSh(4hnnCJUaJh(4hnnCJaJjh(4hnnCJUaJh(4hnn5CJaJ .02Vr}qh_h $Ifgdf $Ifgdd $$Ifa$gdd kd$$Ifl4 \ \ H!` x t644 laf4ytj(%n}xofUQ$If^`Qgdnn $Ifgdd $Ifgdnngd&fkdM$$Ifl4 \ \ H!  x t644 laf4ytj("#$%,-9PRSjkmnopq˿˴˿ӟˇ˿xkӟ_h(4hnn5CJaJhnnCJaJmHnHujohnnCJUaJjhnnCJUaJhnn5CJaJh@l#hnn5hd hnn0JCJaJhnnhnnCJaJjhnnCJUaJhnnCJaJh(4hnnCJaJjh(4hnnCJUaJ#jh(4hnnCJUaJ nop~~ $Ifgdd $Ifgdz ,nkdw$$Ifl4 F \ !`  tG"6    44 laf4ytr`}qhh $Ifgdd $$Ifa$gdd kd'$$Ifl4 \ \ !  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FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable Comments:  FORMTEXT           Questions? Please contact the chair of the Department of Preventive Medicine Dr. Grant Somes (gsomes@utmem.edu). 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