Research Project Information:

Sponsor:

Protocol Number:

BUMC IRB Number

Principal Investigator

Name:

Email:

Site Coordinator

Name:

Email:

Department:

Division:

Address (street, city, state, zip):

Main Contact

Name:

Title:

Phone #

Anticipated Start Date:

Overall Study Duration (months)

How many subjects are you planning to enroll:

How many non-English subjects are you expecting:

How long will the consenting visit take? (hours)

How many follow-up visits will each subject have ?

On average, how long will each follow-up visit take? (hours)

In total, will this study use interpreter services for how many hours?