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Research Core Consultation Request

CHEIR is interested in the development of new projects and proposals related to the advancement in health disparities and health equity research. We can coordinate a team of experts to assist with the review of project ideas that can either be new or project re-submissions. If you have an idea for a research initiative or project, please fill the following Consultation Request Form. You will receive a response within 5 business days so we can schedule a time to meet and discuss your project with the most suitable advisor.

First Name (of person requesting consultation):
Last Name:
Title:
Department:
Division:
Preferred Method of Communication:
   Please enter your phone number (XXX-XXX-XXXX):
   Please enter your email address:
P.I. Name (If different from above):
P.I. Email:
   
The following demographic information about the investigator is collected for CHEIR’s analysis purposes only
What was your sex at birth?
What is your current sex?
Do you consider yourself to be Hispanic/Latino? Yes No
What is your race?
   Please specify (if you chose "Other"):

Project Information

Is this a pilot project? Yes No
Project Title:
Project’s Target Population:
Project’s Setting:
Project Description (Please include scientific background and specific aims):
Is this project funded?
Does the project have IRB approval?
Application Number:
Institution:
Stage of Research:
   Please specify (if you chose "Other"):
Project Deadline Type:
   Please specify (if you chose "Other"):
Project Deadline (MM-DD-YYYY):
Type of Support Requested:
Where did you learn about CHEIR’s consultation services?
Do you expect that this project will produce publications?
Would you be willing to present your project at a CHEIR related seminar?

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