Biostatistics Consulting / Collaboration Request

Name*

First Name

Last Name

Phone

Email*

Faculty Rank*

Faculty Fello Resident Student

Funding

Do you have funds available for statistical support?*

Yes No Funds Pending

Have you allocated funds for data analysis?

Yes No

What percentage of time have you allocated for data analysis?

0 - 5 % 6 - 10 % 10 % or greater I have not allocated funds

How is your project funded? (Federal grant, start-up funds, etc.)

Project Description

Tell us about your project.

What do you need help with?*

Statistical Consultation Study Design & Sample Size Dataset Creation / Database Management Data Analysis / Statistical Analysis More than one of these I don't know

Can you provide us with a brief description of your study?

Dates

When are you starting your project?*

When will you have data collected?*

When do you need request completed?*

If you are writing an abstract, when is it due?

If you are writing a manuscript, when is it due?

Comments or Questions?

Do you have additional questions or comments?

Provide Supporting Documentation for Review

If providing supplemental documentation, please enclose individual codes in double-quotes, followed by a comma and space.
Note that diagnosis codes are hierarchical; (i.e. "A00" would automatically include "A00.01" through "A00.99"). Therefore, "A00.*" should instead be submitted as "A00" only.

An example for ICD codes for Chronic Obstructive Pulmonary Disease is shown below:
COPD = "491.22", "493.21", "491.21", "493.22", "491.20", "493.20", "496", "J44"

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