Investigator name:

Investigator email:

Affiliation (institution):

Department or center:

Phone number:

Are you already working with an Emory collaborator on this line of research? Yes No

Other collaborator names:

Other collaborator institutions:

Other collaborator email addresses:

Proposed start date:

Proposed end date:

Proposed funding source:

Please cut and paste or upload your proposed budget:

Does your study already have IRB approval? Yes No

Is this a training proposal? Yes No

Title of study:

Please cut and paste or upload your study abstract. Include background, research questions or hypothesis/specific aims, data collection methodology, analysis plans.

Please cut and paste or upload your study protocol or summarize if not yet finalized.

How many participants are required?

What are the demographics of your study with respect to age, gender, race, ethnicities, special populations, diagnosis (i.e. cognitive impairment, depression, anxiety, sleep impairment, etc.)?

Does your study collect and use already stored blood, urine, or phenotypic data? Yes No

Will participation by Emory Healthy Aging Study participants require an additional procedure or an additional visit? Yes No

Is there potential for this research to be used when applying for an IND or IDE to the FDA or your country’s government oversight agency? Yes No

What data and/or analyses are needed for the research study? (Please check all that apply)

Newly added data (examples: questionnaires, CT scan, MRI, PET scan, cerebrospinal fluid) – specify item if not shown/detailed in above tables)

Who will pay for lab collection, testing, and specimen storage?

What, if any, follow up is needed? (Specify length of time and events to be ascertained)

What any additional work or personnel time would be expected from Emory Healthy Aging Study staff?

Where will the data analyses be conducted and stored?

What data will be transferred?

When will data be transferred to and from research study staff? (monthly, quarterly, semi-annually, etc.)

How will the data be transferred?

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