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Research Request Form
Please fill out to request information.
Requested by: (Name of Individual, Department, Division, or Committee)
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Contact Name
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First Name
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Last Name
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Affiliation
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Email
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Project Title/Name
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Today’s Date
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What is your anticipated timeline of the study (when would you ideally like the data, and when do you anticipate completing the work and disseminating results)
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Project Description: Abstract (with relevant information on data collection methods and issues of dealing with anonymity or confidentiality)
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Please provide a description of the Purdue Global populations and/or data requested with a description of why this would be relevant to proposed research
*
What questions do you want the data to answer?
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Do you have a survey and/or interview questions to be used?
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Please attach a copy of the survey or interview questions
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Do you have an IRB training certificate from an organization such as CITI or PHRP?
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Yes
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Please attach a copy of the training certificate.
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Do you have an informed consent document?
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Do you have IRB approval?
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Please attach a copy of the approval letter
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Do you have an IRB application?
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Yes
No
Please attach a copy of the IRB application
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Please explain the proposed dissemination plan for the research results.
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