Walk-in Form

Biostatistics, Epidemiology, and Health Services Research Collaboration Request Form

Directions: Fields marked with a * are required. When you are finished entering information, click the "submit" button at the bottom of the form.

CONTACT INFORMATION

Have you previously met with anyone in the Department of Public Health Sciences (PHS)?
	Yes	Name of PHS contact:
	No

PSU Status*:
	Faculty or Staff	Resident or Post-Doc	MS or PhD Student	Medical Student

Medical Students only:

What is your current academic year?
	1	2	3	4

Is this a Medical Student Research (MSR) Project?
	Yes	Advisor Name/Department:
	No

PROJECT INFORMATION
Project Title:
Sponsor/PI:
Project Description Use this space to describe your project and provide details that will help to explain your needs (i.e. description of your data set, questions of interest, methods, etc.).

Is this a grant or contract proposal?*
	Yes	No

Is this project cancer related?
	Yes	No

Type of Collaboration Needed
	Biostatistics
	Epidemiology
	Health Services Research
	Unknown

Request help with (check all that apply):
	Study Design
	Review of Study, Proposal or Protocol
	Sample Size and Power Calculations
	Data Entry or Management
	Advice regarding Data Analysis (plan to perform own analysis)
	Data Analysis and Report (PHS to perform analysis)
	Bioinformatics or Statistical Genetics
	Questionnaire/Survey Design
	Web Site Design
	Database Development
	Application Development
	Other:

Would you consider co-authorship on abstracts, presentations, and manuscripts for PHS collaborators?
	Yes	No

Project Deadline*
	No deadline
	WOULD LIKE completed by: (mm/dd/yyyy)
	NEED completed by: (mm/dd/yyyy)


Project Funding Status*
	Funds available for PHS collaboration	Name of Billing Contact:
	No funds currently available, but PHS will be written into grant/contract for future funding
	No funds available for PHS collaboration