Department of Biostatistics Consulting Request Form

For VICTR-CTSA Voucher Requests and General Consulting Requests to Biostatistics

Telephone: (615) 322-2001 Fax (615) 343-4924

Name:   ____________________________      Date of request:______________________    
Telephone: _________________________      E-mail:_____________________________ 
Department:_________________________      Division: ___________________________          
Center:    _________________________

Are you on the VU faculty? ___ Yes    ___ No   If no, please give the name of the faculty sponsor: 
Faculty sponsor: ________________________________________________________________________
Are you a VICC member?                             ___ Yes      ___ No
Are you a VKC investigator?                        ___ Yes      ___ No

Project or Grant Title:


Project Description: (please check all that apply)
___ The requested services are being used to support a peer-reviewed funded project.   
___ The requested services will be used directly or indirectly to prepare a grant application.
___ The results of this project will be submitted for publication in a peer-reviewed journal.
___ The request is to review feasibility of using previously collected data to answer questions of interest.

Services Requested (check all that apply):
__ Experimental or study design          __ Sample size calculations            __ Data analysis
__ Writing section of grant proposal     __ Data Management                     __ Manuscript Preparation
__ Other, Please specify:_________________________________________________________________

For Grant Proposals:
Agency: ________________________________________
Due Date:______________________                      Proposed Date of Award:______________ 
Administrator for Grant Tracking:  _______________________________________________________
Telephone:__________________                                    E-Mail:___________________

For Other Projects:
Administrator  for Billing (if not covered by CTSA or Surgical Sciences):_________________
Telephone:____________________                                   E-Mail:__________________  

I have read the criteria for co-authorship at
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.

Data Source (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.  Please specify:______________________________________________________________

If the services requested involve analysis of existing data, please check all that apply:
___  The data have been verified against the primary data source
___  The data have been checked for errors
___  The data have been checked for completeness

Objects and Description of Project: Please attach a short (less than one page) description of the project and
its objectives.  State what you would like to learn or to be able to estimate.  If applicable, please make
dependent and independent variables clear.

   To be completed by statistical office.             Date:________________________
   Contact Person:___________________________         Hours worked:________________
   Project short name:________________________        Project number:________________   
Topic revision: r8 - 28 Mar 2011, FrankHarrell

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