ICTR-CAP Consult Request

Institute for Clinical and Translational Research
Community Academic Partnership (ICTR-CAP)

Project Consult Request Form

ICTR-CAP supports research projects on translating new and existing findings into improvements in clinical practice and community health. We engage in a range of activities from brief initial consultations on research to collaboration on grant applications, project implementation and analyses. Some resources are provided free of charge, while other resources are available only to ICTR members and/or have an associated fee.

Investigators receiving ICTR Community Academic Partnership (ICTR-CAP) services agree to cite UW-ICTR by stating in the acknowledgment section of your publications the following message: Supported by grant 1UL1RR025011 from the Clinical and Translational Science Award (CTSA) program of the National Center for Research Resources, National Institutes of Health.

Please complete the following sections.
Fields marked with an asterisk are required.

Descriptive Information

Name: *

Position Title: *

Department/Agency: *

Phone: *

(xxx) yyy-zzzz

Email: *

From whom/how did you learn about ICTR and the Community-Academic Partnerships Core consultation opportunity?:

Interest Areas

I have questions about: (Check all that apply):

Finding a University research partner

Finding a community collaborator for my research project

Obtaining Funding

Study Design

Data Collection and Analysis

IRB submission

Publishing and Research Dissemination

Receiving Education and Training (e.g. via seminar, workshop) in Type 2 translational research

Unique activities

Describe unique activities:

Project Description

Do you have a specific project?:

Yes

Do you have or are you seeking funding for this project?:

Yes

If yes, please indicate funding source:

Do you have a grant deadline?:

Yes

If yes please indicate funding deadline:

Specific Project Summary File:

Please attach a 1-page summary of the project, addressing: 1) Your research question and the significance of this stream of research; 2) The objectives of your study; 3) What you hope to do with the results (e.g., publish, seek funding, evaluate a program); 4) Funding status and type (currently have funding, seeking funding, do not plan to seek funding); 5) Statement of why/for what are you requesting assistance.

If you don’t have a specific project, do you have an idea for a project? :

Yes

Project Idea Summary File:

Please attach a brief summary of the project idea, addressing each of the following headings: 1) why you think the topic is important; 2) what you might want to accomplish; 3) a description of a setting that is appropriate for this area of research.

ICTR Membership

What is your ICTR Membership Status: *

Member

Not a member

UW ICTR

Education & Training

Biostatistics & Informatics

Community Research

Investigator Resources

ICTR-CAP Consult Request

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