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

Name(Required)

If student or fellow, include name of faculty member you will be working under

Department(Required)

Phone Number(Required)

Email Address(Required)

Project Title(Required)

Project description (goals and/or hypothesis):(Required)

[500 words max]

Analysis Plan (variables and analytic approach):(Required)

[1,000 words max]

Goal for this Core service request:(Required)

Grant proposal

Cancer Center Report/Presentation

Peer-reviewed paper publication

Other…

Based on your initial literature review for the proposed project, please describe how your project would uniquely contribute to the science and literature. Please summarize the potential impact that your project could have based on the current literature.(Required)

Is this project funded?(Required)

Yes

Other

How would you pay for this Core service request?(Required)

Existing funding/grants

Pending grants

Request for a fee waiver for the initial phase of the project

Cancer Center directly related request which is exempt from fee-for-service

Has this project received IRB approval?(Required)

No, approval not required

No, approval will be sought

Approval Pending

Yes

Services Area Requested

Large population data analysis including epidemiologic analysis, spatial analysis and visualization, econometric analysis, ecological analysis etc.

Population health measurement and study design including psychometric analysis, survey development, power analysis, complex survey data analysis etc.

Patient reported health outcome measurement and health services research

Economic evaluation including treatment effect analysis, causal inferences, cost-benefit/cost-effectiveness analysis, simulation, economic attribute-based survey design and analysis etc.

Data management for restricted data sets

Population-based cancer research lab/team for grants

Other…

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

PI Contact Information