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Immunology Center Research Request
To be used when one is requesting permission to enroll research participants through the Miriam Immunology Center
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Requesting Investigator:
Last Name:
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First Name:
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Academic Title:
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Academic Title:
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Institution:
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Email Address
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Are you affiliated with The Miriam Hospital Immunology Center
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Yes
No
The Miriam Hospital Immunology Center Collaborator:
All research requests must have a Immunology Center faculty member collaborator.
Last Name:
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First Name:
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Academic Title:
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Email Address:
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Grant/Study Title:
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Principal Investigator:
Last Name:
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First Name:
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Type of funding
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External funding
Internal Funding
Not funded at this time
Funding Agency:
Grant Number (if applicable)
Please provide a brief overview of this study:
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Please provide a brief description on the specific activities that will take place in the Immunology Center
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Number of patients to be recruited
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Eligibility Requirements
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Number of study visits per patient
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How long will the participants be involved in the study?
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Recruitment Start Date:
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Estimated End Date:
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IRB Approval
Please note: IRB approval is required from one of the following mechanisms
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IRB Approval Granted
Waiver of Authorization obtained
Pending
IRB Approval Date
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+
Upload IRB approval documentation
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Upload Waiver of Authorization
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Will Immunology Center research staff be needed?
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Yes
No
Will Immunology Lab support be needed?
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Yes
No
Please describe your research staffing needs:
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Please describe the type of lab services needed:
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If Immunology Center research staff will be needed would you like us to contact them about the service?
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Yes
No
If lab services are needed would you like us to contact them about the service?
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Yes
No
I agree that all manuscripts or public presentations must be reviewed by the appropriate Infectious Disease and/or Immunogy Center faculty. I will acknowledge the support from CFAR and The Miriam Hospital Immunolgy Center, as well as any other relevant grants such as R25 and T32 support, in all manuscripts.
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I agree
Signature
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