NCCHC Research Request Form Summary statement of study(Required)Research team affiliation(s)(Required) Funding sources(Required) IRB status(Required) Not applied for and don't intend to Not applied for but intend to Submitted, not yet approved Submitted, approval conditional upon NCCHC agreeing to participate Fully approved Other NCCHC staff involvement: tasks and personnel required and estimated staff time(Required) Conflict of interest (check all that apply) *(Required) Potential financial benefit for research team in study findings Industry funding A research team member is affiliated with NCCHC or an accredited facility Potential conflict with researcher affiliation None we are aware of Other. Will provide details upon request. Are there copyright, intellectual property, or ownership issues that need to be addressed?(Required) Yes No Maybe/don't know If you answered "yes" or "maybe" to the previous question, please describe potential issues.Dissemination plans, intention to present results publicly (e.g., scholarly publication, conference presentation)(Required)Name(Required) First Last Your Email(Required) PhoneNameThis field is for validation purposes and should be left unchanged.
