QIP Service Request Form

[contact-form][contact-field label=’Requestor%26#039;s Role’ type=’select’ options=’Principal Investigator,Co-Investigator,Project Manager,Research Coordinator,Research Assistant’/][contact-field label=’Requestor%26#039;s Name’ type=’text’/][contact-field label=’Requestor%26#039;s E-mail’ type=’text’/][contact-field label=’Requestor%26#039;s Telephone Number’ type=’text’/][contact-field label=’Principal Investigator%26#039;s Name (if different from requestor)’ type=’text’/][contact-field label=’Department’ type=’select’ options=’HSPH- Biostatistics in AIDS Research,HSPH- Epidemiology,HSPH- Immunology and Infectious Diseases,HSPH- Environmental Health,HSPH- Genetics and Complex Diseases,HSPH- Global Health and Population,HSPH- Health Policy and Management,HSPH- Nutrition,HSPH- Other,HSPH- Department of Social and Behavioral Sciences’/][contact-field label=’Protocol Number (if Assigned)’ type=’text’/][contact-field label=’Study Title’ type=’text’/][contact-field label=’Requested QIP Services’ type=’select’ options=’Submission Assistance (review of application or electronic submission support),Human Subject Grant Review,Study Start-up Assistance,Routine On-Site Review,Regulatory Binder Consultation,External Audit Prep Assistance,On-Site Monitoring,Floating Research Coordinator/Project Manager Support,In-Service,New Research Coordinator Orientation,Other/General Consultation’/][contact-field label=’Other/General Consultation: Please specify topic’ type=’text’/][contact-field label=’QIP In-Service: Please specify topic (if known)’ type=’text’/][contact-field label=’Years participating in research’ type=’select’ options=’0-1,1-5,5-10’/][contact-field label=’Have you worked with QIP in the past’ type=’select’ options=’Yes,No’/][/contact-form]