PeDRA Focused Study Group Application

Proposed Chair

First Name

Last Name

Degree(s)

Email

Primary Affiliation

Proposed Vice Chair

First Name

Last Name

Degree(s)

Email

Primary Affiliation

Proposed Focused Study Group Information

Focused Study Group Name

What diseases/conditions/etc will this group encompass?

Current and anticipated studies:

What Focused Study Group have these studies lived under previously?

Rationale for creating a new FSG:

Group Members (optional)

Please list all individuals interested in forming this Focused Study Group. It's okay to provide only first and last name of each individual. PeDRA may contact you for additional details later. You may add up to 12 interested group members, please email Katherine Devenport (katherine.devenport@pedraresearch.org) with any additional members.

Co-Investigator 1

First

Last

Degree(s)

Affiliation

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Co-Investigator 2

First

Last

Degree(s)

Affiliation

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Co-Investigator 3

First

Last

Degree(s)

Affiliation

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Co-Investigator 4

First

Last

Degree(s)

Affiliation

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Co-Investigator 5

First

Last

Degree(s)

Affiliation

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Co-Investigator 6

First

Last

Degree(s)

Affiliation

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Co-Investigator 7

First

Last

Degree(s)

Affiliation

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Co-Investigator 8

First

Last

Degree(s)

Affiliation

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Co-Investigator 9

First

Last

Degree(s)

Affiliation

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Co-Investigator 10

First

Last

Degree(s)

Affiliation

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Co-Investigator 11

First

Last

Degree(s)

Affiliation

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Co-Investigator 12

First

Last

Degree(s)

Affiliation

By selecting the box below, the chairs agree to satisfy the terms of a Focused Study Group as described in the FSG definition.

I Agree

Contact Information