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University of Virginia
Department of Public Health Sciences
Division of Biostatistics and Epidemiology
Box 800717 School of Medicine

Telephone: (434) 924-8712

Fax: (434) 924-8437

Request for Services or Collaboration

Last Name:*

First Name:*

Department:

Division:

Email Address:*

Request Date:*

Are you on the UVa faculty?:

Yes No

If No, please give the name of your faculty sponsor:

Is this a UVa Cancer Center project?:

Yes No

Is this a GCRC project?:

Yes No

Are you or the project P.I. a member of the UVa Cancer Center?:

Yes No

Project or Grant Title*

Project Description (please choose all that apply):

The services of the Division are being used to support a peer-reviewed funded project. The services of the Division will be used to prepare a grant application The results of this project will be submitted for publication in a peer-reviewed journal. Review feasibility of using previously collected data to answer questions of interest.

Services Requested (please check all that apply)

Experimental or study design Writing section of grant proposal Sample Size Calculations Data Management Data Analysis Manuscript Preparation Other (specify below)

Other Service(s)

For Grant Proposals:

Agency

Due Date

Proposed Date of Award:

Administrator for Grant Tracking:

Telephone:

Email Address

For Other Projects:

Administrator for Billing:

Phone

Email Address

Criteria for Co-Authorship

I have read the criteria for co-authorship and agree with these criteria. In particular, I agree that determination of authorship for any papers resulting from this work is independent of any charges for work performed.

Yes No

Data Source (please check all that apply)

Existing observational database Interim data from a clinical trial Research database specifically for this project Data not yet collected Existing (closed) randomized clinical trial database Other (specify below)

Other data source:

Objects and Description of Project: (State what you would like to learn or to be able to estimate. If applicable, please make dependent and independent variables clear.

Last modified on: February 10, 2006

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