Research & Clinical Trials Submit a Research Proposal Submit a Research Proposal To submit a research proposal, please complete the following form. * Required Fields Full Project Title * Principal Investigator (PI) * Academic Affiliation or CoxHealth Department * Phone * Email * Address * Other Personnel Involved with Project (Name, Title) Project Summary * Provide a summary of the research question, objectives, intervention/interaction with human subjects and how the project will contribute to the generalizable knowledge Will recruiting materials be used? * Yes No Please upload any advertisement, flyers, phone script, etc. that will be used. Is the project funded by any federal government agency or grant? * Yes No What departments are impacted by this project? * Has administrative or executive approval been provided for their involvement? * Yes No N/A Please attach letter or email of approval ¬Has this project previously been reviewed by any other institutional review board (IRB)? * Yes No If yes, please upload the IRB determination. Does the project include physical procedures by which information or biospecimens are gathered and/or manipulation of the participant or the participant’s environment? * Yes No Will informed consent of study participants be obtained? * Yes No Please attach informed consent document Describe risks to study participants and how risks will be minimized * Please describe any anticipated benefits to participants in this study * Description of the study population * Provide criteria for study participant screening, inclusion, exclusion, and measures to ensure equitable participant selection or data sampling including how participants or data will be identified. Proposed number of participants or records? * Will participants receive anything of value for participation? * Yes No Data collection * Provide a specific list of what information or biospecimens will be collected and how and from where it will be obtained. If clinical data, provide the elements and definitions. If surveys or similar instruments will be used, upload a copy of the instrument. Does the information to be collected require access to electronic medical records? * Yes No Will the information to be collected contain any personal identifiable information (PII)? * View https://www.dol.gov/general/ppii for more information on what is considered PII. Yes No Describe provisions to protect the privacy of study participants and to maintain confidentiality of data. Describe how data will be stored, protected and destroyed. * Provide a core sample of references supporting the project proposal research question, methods, target population and data. *