Request for CRRO Services CRRO Services Request 1) Please provide a brief description of your request*Name of the person submitting this consultation request* First Last Will you be the main person working with the CRRO for the consultation?*YesNo 2) Contact information for the person who will be working with CRRO for this consultationMain person's name* First Last Main person's role in this study*Coordinator/ManagerPIPI/FellowPI/ResidentPI/StudentFellowPost-docResidentScholarStudent/DoctoralStudent/DentalStudent/Master'sStudent/MedicalStudent/PharmacyStudent/OtherOtherPlease provide main person's title or role if "Other"*Main person's email address* Main person's phone*Main person's School*School:MEDGSDMSPHGMSCRCOtherPlease enter main person's School if you selected Other*Main person's Department-MED*Department:No selectionAdministration, BUMCAdministration, BUSMAdmissions (MED)AlumniAnatomy & NeurobiologyAnesthesiologyArthritis CenterBiochemistryCancer Research CenterClinical AffairsContinuing Medical EducationDermatologyDiversity and Multicultural AffairsEmergency MedicineFamily MedicineGeneral Clinical Research CenterGenome Science InstituteMedical EducationMedicineMicrobiologyNational Emerging Infectious Disease LabNeurologyNeurosurgeryObstetrics & GynecologyOffice of Academic AffairsOphthalmologyOrthopaedic SurgeryOtolaryngology-Head & Neck SurgeryPathology & Laboratory MedicinePediatricsPharmacology & Experimental TherapeuticsPhysiology & BiophysicsPsychiatryPulmonary CenterRadiation OncologyRadiologyRehabilitation MedicineSlone Epidemiology CenterSociomedical SciencesStudent AffairsSurgeryWomen's Health Interdiscp Research CtrMain person's Department-GSDM*Department:No selectionAcademic AffairsAdmissions & Student ServicesClinical Research CenterContinuing EducationDean's OfficeDental Health CenterDiagnostic Sciences & Patient ServicesEndodonticsGeneral DentistryHealth Policy & Health Svcs ResearchImplantology, Center forInstitute for Dental Research & Education (Dubai)Molecular & Cell BiologyOperative DentistryOral & Maxillofacial PathologyOral & Maxillofacial SurgeryOrthodontics & Dentofacial OrthopedicsPediatric DentistryPeriodontology & Oral BiologyRestorative Sciences & BiomaterialsMain person's Department-SPH*Department:No selectionBiostatisticsCenter for Global Health & DevelopmentCommunity Health SciencesDoctoral EducationEnvironmental HealthEpidemiologyGlobal HealthHealth & Disabilities Research InstituteHealth Law, Bioethics & Human RightsHealth Policy & ManagementInstitutional DevelopmentInternational Health (DIH)Join TogetherMaternal & Child HealthNational Institute on Alcohol Abuse and AlcoholismPublic Health PracticeResearchSocial & Behavioral SciencesMain person's Department-GMS*Department:Anatomy & NeurobiologyBiochemistryDermatologyMedicineMicrobiologyPathology & Laboratory MedicinePharmacology & Experimental TherapeuticsPhysiology & BiophysicsOtherPlease enter main person's GMS Department if you selected Other.*Main person's School/Department--CRC*Please enter your school and department affiliation at CRCMain person's Section-Department of Medicine*Section:No selectionBiomedical GeneticsBiomolecular Medicine UnitCardiovascular MedicineClinical Epi Research & TrainingComputational BiomedicineDigital Imaging Microscopy CtrEndocrinology, Diabetes & NutritionGastroenterologyGeneral Internal MedicineGeriatricsHematology & Medical OncologyHypertensionImmunotherapy UnitInfectious DiseaseIon Channel & Calcium Signaling UnitMedical Information Systems UnitMolecular GeneticsObesityPreventive Medicine & EpidemiologyPulmonary, Allergy, Sleep & Critical CareRenalRheumatology (Arthritis)Roger Williams Med CtrStress Response, Center forVA Medical Center, BostonVascular Biology UnitMain person'sSection-Department of Obstetrics & GynecologySection:No selectionGeneral OB/GYNGynecologic OncologyMaternal & FetalOther OB/GYNReproductive EndocrinologyMain person's Section-Department of Pediatrics*Section:No selectionAcademic Affairs,Vice ChairAmbulatory Care ServicesChild DevelopmentChild NeurologyClinical Affairs,Vice ChairCommunity PediatricsCritical CareEmergency MedicineGeneral PediatricsGeneticsInfectious DiseaseNeonatologyOther PediatricsPediatric CardiologyPediatric EndocrinologyPediatric GastroenterologyPediatric HematologyPediatric NephrologyPediatric Nutrition and FitnessPediatric Pulmonary & AllergyMain person's Section-Department of Radiology*Section:No selectionBody ImagingBreast ImagingEmergency RadiologyGeneral RadiologyMusculoskeletal RadiologyNeuroradiologyNuclear MedicineNuclear RadiologyOncologic RadiologyPediatric RadiologyQuincy Medical CenterRadiological PhysicsVA Medical Center BostonVascular/Interventional RadiologyMain person's Section-Department of Surgery*Section:No selectionAdvanced Minimally Invasive SurgeryCardiothoracic SurgeryColorectal SurgeryCritical CareGastrointestinal SurgeryGeneral SurgeryOther SurgeryPediatric SurgeryPlastic SurgeryPodiatry SurgerySurgical OncologyTransplant SurgeryTrauma SurgeryVascular Surgery If you have provided the information below for previous CRRO consultations, you may skip to question 3. Main person's degree(s)Main person's faculty rank (if applicable)Rank:InstructorAssistant ProfessorAssociate ProfessorProfessorResearch InstructorResearch Assistant ProfessorResearch Associate ProfessorResearch ProfessorNone 3) PI InformationIs the PI the same as the main person working with the CRRO for the consultation (identified above)?*YesNoPI Name* First Last PI Type*PI/FacultyPI/BMC FellowPI/Fellow-OtherPI/BMC ResidentPI/Resident-OtherPI/Student-MedicalPI/Student-DentalPI/Student-SPHPI/Student-DoctoralPI/Student-Master'sPI/Student-PharmacyPI/OtherPI's DegreePI's Faculty Rank (if applicable)Rank:InstructorAssistant ProfessorAssociate ProfessorProfessorResearch InstructorResearch Assistant ProfessorResearch Associate ProfessorResearch ProfessorNonePI's Email* PI's Phone*PI's School*School:MEDGSDMSPHGMSCRCOtherPlease enter PI's School if you selected Other.*PI's Department-MED*Department:No selectionAdministration, BUMCAdministration, BUSMAdmissions (MED)AlumniAnatomy & NeurobiologyAnesthesiologyArthritis CenterBiochemistryCancer Research CenterClinical AffairsContinuing Medical EducationDermatologyDiversity and Multicultural AffairsEmergency MedicineFamily MedicineGeneral Clinical Research CenterGenome Science InstituteGraduate Medical Sciences, Division ofMedicineMedical EducationMicrobiologyNational Emerging Infectious Disease LabNeurologyNeurosurgeryObstetrics & GynecologyOffice of Academic AffairsOphthalmologyOrthopaedic SurgeryOtolaryngology-Head & Neck SurgeryPathology & Laboratory MedicinePediatricsPharmacology & Experimental TherapeuticsPhysiology & BiophysicsPsychiatryPulmonary CenterRadiation OncologyRadiologyRehabilitation MedicineSlone Epidemiology CenterSociomedical SciencesStudent AffairsSurgeryWomen's Health Interdiscp Research CtrPI's Department-GSDM*Department:No seletionAcademic AffairsAdmissions & Student ServicesClinical Research CenterContinuing EducationDean's OfficeDental Health CenterDiagnostic Sciences & Patient ServicesEndodonticsGeneral DentistryHealth Policy & Health Svcs ResearchImplantology, Center forInstitute for Dental Research & Education (Dubai)Molecular & Cell BiologyOperative DentistryOral & Maxillofacial PathologyOral & Maxillofacial SurgeryOrthodontics & Dentofacial OrthopedicsPediatric DentistryPeriodontology & Oral BiologyRestorative Sciences & BiomaterialsPI's Department-SPH*Department:No selectionBiostatisticsCenter for Global Health & DevelopmentCommunity Health SciencesDoctoral EducationEnvironmental HealthEpidemiologyGlobal HealthHealth & Disabilities Research InstituteHealth Law, Bioethics & Human RightsHealth Policy & ManagementInstitutional DevelopmentInternational Health (DIH)Join TogetherMaternal & Child HealthNational Institute on Alcohol Abuse and AlcoholismPublic Health PracticeResearchSocial & Behavioral SciencesPI's Department GMS*Anatomy & NeurobiologyBiochemistryDermatologyMedicineMicrobiologyPathology & Laboratory MedicinePharmacology & Experimental TherapeuticsPhysiology & BiophysicsOtherPlease enter PI's GMS Department if you selected Other.*PI's School/Department-CRC*Please enter school and department affiliation at CRC.PI's Section-Department of Medicine*Section:No selectionBiomedical GeneticsBiomolecular Medicine UnitCardiovascular MedicineClinical Epi Research & TrainingComputational BiomedicineDigital Imaging Microscopy CtrEndocrinology, Diabetes & NutritionGastroenterologyGeneral Internal MedicineGeriatricsHematology & Medical OncologyHypertensionImmunotherapy UnitInfectious DiseaseIon Channel & Calcium Signaling UnitMedical Information Systems UnitMolecular GeneticsObesityPreventive Medicine & EpidemiologyPulmonary, Allergy, Sleep & Critical CareRenalRheumatology (Arthritis)Roger Williams Med CtrStress Response, Center forVA Medical Center, BostonVascular Biology UnitPI's Section-Department of Obstetrics and Gynecology*Section:No selectionGeneral OB/GYNGynecologic OncologyMaternal & FetalOther OB/GYNReproductive EndocrinologyPI's Section-Department of Pediatrics*Section:No selectionAcademic Affairs,Vice ChairAmbulatory Care ServicesChild DevelopmentChild NeurologyClinical Affairs,Vice ChairCommunity PediatricsCritical CareEmergency MedicineGeneral PediatricsGeneticsInfectious DiseaseNeonatologyOther PediatricsPediatric CardiologyPediatric EndocrinologyPediatric GastroenterologyPediatric HematologyPediatric NephrologyPediatric Nutrition and FitnessPediatric Pulmonary & AllergyPI's Section-Department of Radiology*Section:No selectionBody ImagingBreast ImagingEmergency RadiologyGeneral RadiologyMusculoskeletal RadiologyNeuroradiologyNuclear MedicineNuclear RadiologyOncologic RadiologyPediatric RadiologyQuincy Medical CenterRadiological PhysicsVA Medical Center BostonVascular/Interventional RadiologyPI's Section-Department of Surgery*Section:No selectionAdvanced Minimally Invasive SurgeryCardiothoracic SurgeryColorectal SurgeryCritical CareGastrointestinal SurgeryGeneral SurgeryOther SurgeryPediatric SurgeryPlastic SurgeryPodiatry SurgerySurgical OncologyTransplant SurgeryTrauma SurgeryVascular Surgery 4) PI eRA Commons NameDoes the PI have an eRA Commons name?*YesNoPI's NIH eRA Commons nameThe PI's NIH eRA Commons ID is necessary for the CRRO to obtain credit for the consultation to support the CTSI grant. The eRA Commons ID is given by NIH to principal investigators at institutions/organizations to access and share administrative information relating to research grants. If the PI does not have an eRA Commons ID, he/she must obtain one to ensure proper credit for this consultation. If the PI is a BUMC or CRC investigator, please visit (http://www.bu.edu/researchsupport/forms-policies/request-for-era-commons-access/). If the PI is a Boston Medical Center investigator, please contact the BMC Grants Administration office through (grants.admin@bmc.org) with the following information: --Full name --Email address. --eRA Commons Role (Postdoc, PI, Trainee, etc.) Which grants office do you typically use, or if you are a student or trainee, which does your mentor typically use?Grants Office:BU-CRCBUMCBMCOtherN/A 5) Study InformationStudy name/Project title (if applicable)Study IRB Number (if applicable)For funded projects, please indicate funder here.Funder grant or project numberBUMC or BMC grant/account number 6) Student/Trainee ResearchIs the study that will be the subject of this consultation considered student/trainee research? That is, the study is being conducted to provide research experience or to satisfy a program requirement for a student or trainee (includes residents and fellows).*YesNoIf you answered No, skip to section 7.Is the student/trainee the same person as the PI identified in Section 3?*YesNoStudent/Trainee Name* First Last Faculty Advisor Name*Type of student/trainee*Student/trainee type:BMC FellowBMC ResidentFellow/OtherResident/OtherStudent/MedicalStudent/DentalStudent/SPHStudent/DoctoralStudent/MastersStudent/PharmacyStudent/OtherTrainee's School*School:MEDGSDMSPHGMSCRCOtherPlease enter Trainee's school if you selected Other*Research is required by*Not requiredTraining programSpecific courseIf research is required by a specific course, what is the course number?*If research is required by a training program, please describe*7) If this is your first time contacting the CRRO, please let us know how you heard about the office.