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
Stage *
Full Title *
Study Type *
Description *
Maximum of 1500 characters allowed. Currently Entered: 0 characters.
Sample Size *
How was the Sample Size derived, and by who? *
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 NO, do you require help finding a funder? *

If NO, do you require help finding a funder? No Yes
If YES, Proposed Funder
Funding limit for proposed funding call
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 'Funder in place', Funder Name
Amount of funding (if known)
Start of study / DD / MM YYYY
Proposed duration of study, (in months):
Sponsor
CTU 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 (e.g. via MACRO) Quality Assurance 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.
Have you had initial discussions with NWORTH about your project?

Have you had initial discussions with NWORTH about your project? Yes No
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

CTU Collaboration

Proposed Meeting Times

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.

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.