Research Support Form

First Name (required)

Last Name (required)

Address 1 (required)

Address 2

City (required)

State/Province (required)

Country (required)

Zip/Postal Code (required)

Phone
(required)

Email (required)

Curriculum Vitae (CV)

2. Detailed Overview of the Intended Study

Study Title (required)

What is the hypothesis or fundamental question/s that this study aims to be able to answer? (required)

What are the important study parameters that will be measured? (required)

How may the study results potentially advance clinical outcomes for patients? (required)

Who is the lead/principal investigator of the study? (required)

What is the estimated time frame for this study? (required)

Will this study be peer reviewed? (required)

Yes

What is the name of the Society or Journal that the study is intended to be submitted to for publication? (required)

Please declare any disclosures, conflicts and/or potential conflicts of interest that you or your co-clinical investigators may have with this study:

3. Protocol

Please check all that apply:

Does this study have a ClinicalTrials.gov identifier assigned from the National Institutes of Health?

Is this a Prospective study?

Is this a Retrospective study?

Is this a Patient study?

Is this a "Randomized" study?

Is this a "Blinded" study?

What is the NIH study identifier number?

How many patients to be enrolled in the study?

Please upload the proposed study protocol

What is the status of your institution’s IRB or Ethics Committee approval for this study?

Not Submitted

Submitted

Approved

4. Data and Analysis

How will the data for this study be collected?

If available, please attach a copy of the approved case report form (CRF) to be used for this study

Will a statistical analysis of the data be conducted?

Yes

Who will be responsible for conducting the statistical analysis?

How will any bias be eliminated from this study?

5. Budget Details

Please indicate the type of support required for this study

Financial

Product

Please attach your budget here for review:

Please list what products and quantity you require for support and/or amount of financial support requested:

Applied Medical Product Catalog

Have you submitted a request for support of this study to other industry partners?

Yes

Please list all company names:

Which companies above have agreed to support?