NWORTH Collaboration Request Form

Please use this form to contact us with a request for collaboration.

Date request made * / DD / MM YYYY
Investigator
Name *
Role *
Employer *
Location *
Department
Contact Number *
Email Address *
Study Details
Full Title *
Stage *
Study Type *
Description *
Maximum of 500 characters allowed. Currently Entered: 0 characters.
Sample Size *
How was the Sample Size derived? *
Maximum of 300 characters allowed. Currently Entered: 0 characters.
Please give some information on how the sample size was derived.
Proposed Number of Sites *
Funding & Sponsorship
Do you have funder in mind? *

Do you have funder in mind? No Yes Funder in place
If YES, please provide further details:
Proposed Funder:
Funding application deadline / DD / MM YYYY
Proposed start of study / DD / MM YYYY
Proposed duration of study, (in months): *
Proposed sponsor
Has the sponsorship been agreed?

Has the sponsorship been agreed? Yes No Provisional
If NO,
Do you require help applying for funding

If NO,
Do you require help applying for funding Yes No
If Funder in place

Please complete this section if you already have a funder in place
Funder
Start of study / DD / MM YYYY
Proposed duration of study, (in months):
Sponsor
Has the sponsorship been agreed?

Has the sponsorship been agreed? Yes No Provisional
Collaboration
Please select our services below that are required for this trial. *
Study Design / Methodology Study / Trial Management Sample Size Statistical Oversight Study Statistician & Statistical Analysis Web Based randomisation service Web based Electronic Data Capture of Outcome Measures (e.g. via MACRO) Web based Electronic Data Capture of Adherence Measure (e.g. via MACRO) Web based Electronic Data Capture of Adverse events (e.g. via MACRO) Web based Consort/Monitoring Quality Assurance LLAIS (Welsh Language Support) Social Care input Other (please outline) Other (please outline)
Proposed Meeting Times
Please propose a date for an initial meeting. / DD / MM YYYY
Additional Information:

If you have any supporting documentation, (e.g. draft proposal, protocol, links, references or details re sample size/power calculation), which will provide more information for the reviewing team, please forward to: nworth@bangor.ac.uk

This will help to speed up the review process.
Any Further Comments:
Maximum of 300 characters allowed. Currently Entered: 0 characters.

NWORTH Collaboration Request Form

NWORTH Collaboration Request Form

Investigator

Study Details

Funding & Sponsorship

If Funder in place

Collaboration

Proposed Meeting Times

Additional Information: