Clinical and Translational Science Institute
Populations & Community Engagement Core
Community Research Van – Project Checklist
1. Project Title:
Click here to enter text.
2. Applicant Information
Name:
Click here to enter text.
Position:
Click here to enter text.
Role on Project: Click here to enter text.
Department: Click here to enter text.
Email:
Click here to enter text.
Phone:
Click here to enter text.
3. Community Collaborator
Partner Name: .
Organization: .
Role on Project: .
Address:
.
Email:
.
Phone:
.
If none, please check here ☐ and continue on to question 4.
Have these collaborators worked together in the past?
4. Driver Information
Name:
DL Number:
Email:
Phone:
☐Yes ☐No
.
.
.
.
☐I would like to request that the CTSI find a driver.
5. Van Usage Requirements
Dates needed:
Geographic location:
Click here to enter a date. to Click here to enter a date.
Click here to enter text.
6. Van Resources
☐ DXA: provide documentation of DXA certification or plans for training below:
Certification Documentation/Plan: .
☐ seca weight/height scale
☐ Finger-stick blood sampling
Specify any needed lab supplies: .
☐ Automated blood pressure machine
☐ Stair Stepper
☐ Heart-rate monitoring
☐ Computer
Describe software/hardware needs: .
☐Other equipment, describe: .
☐ Other supplies, describe: .
Clinical and Translational Science Institute
Populations & Community Engagement Core
Community Research Van – Project Checklist
7. IRB Approval
Has this study been approved by the IRB?
If yes:
IRB study number: .
IRB approval date: .
8. Has this study been funded?
Funding Agency/Sponsor:
If yes:
Grant # or Protocol #:
If pending: Anticipated decision date:
☐Yes ☐No
☐Pending
☐Yes ☐No
☐Pending
☐Yes ☐No
☐Pending
.
.
.
9. Has this study been peer-reviewed elsewhere?
If yes:
Name of review group:
.
If pending: Anticipated decision date:
.
10. Please append the project narrative, not to exceed 3 pages and font size no smaller than 11 point, to
the end of this document.
This project narrative should address the following:

What health issue or priority is this project proposing to address?

What is the significance and relevance of the health issue to communities in Minnesota (or
neighboring state)?

Why is the Van needed for the particular research study that is being proposed?

Provide a brief description of research plan including the:
◦
project design,
◦
study population,
◦
data collection and analysis methods, and
◦
dissemination plan.

What is the plan for continuing the research beyond the pilot phase?
11. Please include any applicable letters of collaboration and support following the project narrative.
12. Please convert the entire application packet (this form, the project narrative, and any supporting
letters) into a PDF and submit it to: ctsivan@umn.edu
Click here to enter text.
Applicant Typed Signature
Click here to enter a date.
Date