Center for Surgery and Public Health
Request for Biostatistical/Programming Services and Study Design Support
Instructions: Please complete this form and submit it to Tammy Ballard at
tgilsonballard@partners.org. If you have any questions, Tammy can be reached at
617-525-9846.
Date:
Principal Investigator:
Co-Investigators:
Project Title:
Project Abstract/Goal(s) of Study: (In the space below, please provide an abstract of your
research protocol and alignment with Center goals - two-three sentences.)
CSPH Member:
YES
NO (If no, indicated level of interest in CSPH.)
What type of service are you requesting? Please check all that apply.
Study Design
Data Manipulation
Data Analysis
What is the purpose of your request? Please check all that apply.
Abstract
Manuscript
Grant Proposal
Please include deadline ________
Programming /biostat support start date: ________
Anticipated end date: ________
Have you been awarded funding to support biostat/programming for this research?
Yes ____ No ___
If yes: Please provide source of funding: ___________________________________
Duration of funding: _____________________
Are you seeking funding for this research?
Yes ____ No ____
If no, what are your long term plans for this research?
Signature of PI: ___________________________
Date: _____________________