Population Health and Cancer Outcomes Core (PHCOC) Service Request Form

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Please complete this form to request Core services. Initial consultations for each new project are free of charge – please indicate the services you would like to discuss for your project. A Core member will contact you within two business days to discuss your project, a free consult (if needed), and any related charges. By receiving PHCOC support or services, you agree to acknowledge the Core in all publications or presentations. Please direct questions to Dr. Raj Balkrishnan: rb9ap@virginia.edu

Today's Date

Project Title

Requester's Name

Principal Investigator's Name (If student or fellow, include name of faculty member you will be working under) *

Email Address

Phone Number

Department

Please provide a brief (3 to 4 sentence) description of your project:

How will you be making payment for Core services? (Billing will not occur until after initial discussion and/or complimentary consultation.)

I will use an existing PTAO(s).

I am currently waiting for a PTAO to be established.

I would like to apply for a fee waiver (for internal requests and community partners only).

Other

PTAO Number

Other Payment Method

What is the funding source for this project?

Has this project received IRB approval?

Yes

Approval Pending

IRB approval will be sought

IRB approval not required

Other…

By when do you need our services completed?