The College Diabetes Network: Research Assistance Request

First Name

Last Name

E-mail Address

University Affiliated with Research

Organization Affiliated with Research

Project/Study Type

Please select... Undergraduate capstone/thesis project Master's thesis Doctoral candidate dissertation Institutional faculty research project/study Other Company sponsored project/study

If other, please explain.

Project Title

Source of project funding

Please select... Government (NIH/NIDDK) Foundation Company Sponsored Internal Budget Other Unfunded

If other, please explain.

Briefly describe the research project that you are working on.

Please list the objectives of your study and what you intend to use the findings for.

Please briefly describe how you picture CDN's involvement in this study.

What kind of research is this?

Please select... Phase I clinical trial Phase II clinical trial Phase III clinical trial Phase IV clinical trial Case control study Cohort study Other

If other, please explain

How many participants are you looking to recruit? An approximate number is fine. 

Do you plan on issuing incentives for CDN participants?

YesNoUndecidedNot applicable

Description of incentives

What type of participation are you expecting from individuals participating in the study?

Please select... Single Time Survey Repeated Surveys Biological Specimen Collection Trial Participation Other

If other, please explain.

Please list any other organizations involved in the study and how they are involved.

If there is a link relative to your research study (i.e online survey) please include it here.

When will this research study begin?

When will this research study end?

Status of IRB approval

Please select... Approval Received Approval Pending Not yet submitted Not seeking IRB approval

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