Please fill out the following form to request collaborative services provided by the CBQM. If you have any questions, let us know by completing our contact form.

Contact Information

First Name

Last Name

Email Address

Professional Title

Department/Division/Center

Which best describes your role? Faculty
Staff
Fellow
Post-Doc Researcher
Resident
Grad Student
Med Student
Other Role

Specify other role:

Study Status and Funding

What is the status of the study or project associated with this request for CBQM services? Project/Study is in the early stages of proposal development for future funding
Project/Study has received funding
Project/Study does not have funding

External Due Date for the Proposal:

A CBQM collaborator will reach out to discuss potential funding options.

Status Notice of award received but no research activities have started
Project/study is active and related research activities are ongoing (e.g., recruitment, enrollment, data collection, data analysis)

What is your funding source?

NIH
PCORI
AHRQ
Institutional Support
Other or Unknown

State mechanism (e.g., R01, K23, etc.) Optional: provide link to RFA

Optional: provide link to PFA

State mechanism (e.g., R01, K23, etc.) Optional: provide link to RFA

State mechanism (e.g., CTSI pilot award, DGIM funding)

Specify other source:

Project Information

Who is the PI for this project?

First Name

Last Name

What is the project’s anticipated start and completion date?

Anticipated Start Date:

Anticipated Completion Date:

Please provide a brief description of your project, including study design (if known), project aims, and deliverables (e.g. abstract, manuscript, etc):

What collaborative services would you like to discuss with a CBQM collaborator? Check all that apply.

Study design/sample size/statistical approach sections of grant proposal
Database development and/or data management
Statistical analysis
Qualitative analysis
Clinical Trial collaboration (e.g. data coordinating center)
PRO (Patient-Reported Outcome) Core
Other (specify)/not sure :

Specify:

Collaboration History

Have you ever collaborated with or are you currently working with a CBQM faculty or staff member? Yes
No

Name of previous/current collaborator:

Have you consulted with any other methodologist for this project? Yes, and they will continue to work on this project.
Yes, but they will not continue to work on this project.
No

Name of methodologist:

Additional Information

Please provide any additional comments or information regarding your request that you feel would be helpful:

I attest that I have read and reviewed the CBQM Policies by submitting this intake form. I understand that by clicking submit, I agree this is an intake form only and does not obligate CBQM to offer services.