Collaboration Interest Form

Please complete this form with as much detail as is possible. The information will be used to match your project with the most appropriate CRE collaborator.

Our team meets weekly to discuss all new projects. We will contact you as soon as we have received the completed form and our team has met to discuss your request.

All fields are required unless indicated otherwise.

Client Type

Please check client type: UMU client       Non-UMU client

Client Information

Name:

Department:

Agency/Organization:

Phone:

Fax: (optional)

E-mail:

Title: Faculty Fellow Resident Other, please specify:

Project Information

Project Title:

Service Required: Please check all that apply

Study Design Questionnaire Development Statistical Plan Database Development

Data Collection Strategies Sample Size/Power Calculation Analysis and Interpretation Other, please specify:

Purpose: (Please check all that apply)

Meeting Abstract Pilot Project Project Analysis	Manuscript Presentation Program Evaluation
Extramural Funding Application (note source below)

Timeline:

Grant Deadline : Abstract date :	Presentation date : No Fixed Deadlines
Any other pertinent deadlines:

Is funding currently available for this project:
Current funds available Seeking Funding Non-funded

Scope of work detail:

Contact:

Ellen Jones
Office Manager
Office Phone: 315 464-4430
Fax: 315 464-4429