Research project Staff
To comply with Northwestern University Research Ethics training, please visit http://irb.northwestern.edu/training/citi
Principle Investigator *
Principle Investigator
Principle Investigator Phone Number *
Principle Investigator Phone Number
Project Coordinator (if different from PI)
Project Coordinator (if different from PI)
Project Coordinator Phone Number
Project Coordinator Phone Number
Data Analyst *
Data Analyst
Data Analyst Phone Number *
Data Analyst Phone Number
Data Steward *
Data Steward
Data Steward Phone Number *
Data Steward Phone Number
Please write a brief description about your project.
Type of Request:
Data Elements to be collected:
Please describe desired data for each marked category below.
Numbers Only
Please include a brief description.
IRB/Site Approval (If preparatory to research, check "Not Applicable" for affiliation type and proceed to next section)
Affiliation Type: *
IRB Risk Review: *
Data Collection Starts:
Data Collection Starts:
Data Collection Ends:
Data Collection Ends:
An official quotation based on requested work or hours will be sent for approval.
Will participants receive an incentive?
Intention of Data Use:
Attachments (if applicable):
Please email zahra.hosseinian@northwestern.edu
Fill in blank in following text box by scrolling down and entering your response in the box.
Signature *
Signature
PI Name - this will be considered your signature agreement
PI Agreement Date *
PI Agreement Date
Date form was completed