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---+ 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 <verbatim> 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 Is your primary appointment in Surgical Sciences? ___ 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. </verbatim> --- <verbatim> 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 http://biostat.mc.vanderbilt.edu/ManuscriptPolicies 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. Initials__________ 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:________________ </verbatim>
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Topic revision: r7 - 21 Jul 2010,
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