Research Submission Form

Researcher Name:
Institution:
Address:
City
State:
Zip:
Daytime Phone:
Fax:
Email Address:

Contact information for people interested in participating or who have questions about participating (if different from above):

Summary of study:

Description of research including methodology:

Eligibility Requirement for participants:

Funding Sources:

Enrollment dates: to

Date approved by Institutional IRB

Which Institution?

Please post on web: to

Research is subject to approval by the Oley Research Committee before it is printed in the LifelineLetter or posted on our web page. If you have any questions please email BishopJ@mail.amc.edu or call (800) 776-6539.