COVID-19 Clinical Research Coordination Request Form

Instructions

This form will help us understand your needs and how best to support you through our coordination efforts. Please fill it in to the best of your ability and attach your study protocol with this submission (if applicable). At any time, you may save the data entered into the project form and a link will be sent to the email address you entered for you to complete the online submission at a later time.

These are the principles that we use to coordinate your request:

Needs: What are the requested services?
Relevance/Significance: Why does the research matter?
Effectiveness: Will the research achieve its objectives?
Patient Engagement: Has the study engaged patient partners in its planning or future implementation?
Feasibility: Can the research be done?
Efficiency: Is the research a good use of resources?
Financial Support: Is funding available to support the services required?

1.1

Provide a brief title for your proposed project.

* must provide value

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1.2

Indicate who will lead the proposed project.

Name (First, Last)	Title(s)	Organizational affiliation(s)	Organizational email address

1.3

List other collaborators or team members.

Name (First, Last)	Title(s)	Organizational affiliation(s)	Organizational email address

Name

Title

Organizational Affiliation

1.4

Do you require the participation of health authorities?

Yes

reset

1.5

If you have already established a Health Authority contact(s) indicate who your contacts are.

Name (First, Last)

Title

Organizational affiliation(s)

Organizational Email address

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.