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Consultation Service Intake Form

For questions about our consultation services or this form, please contact the CTSI Integrating Special Populations Program Manager, Nathalie Vizueta (specialpop@mednet.ucla.edu, 310-794-2744).

Please complete this form to help us coordinate your consultation.

What type of referral is this?

* must provide value

Self-referral

Referral for someone else

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Referral made by (Your last name, first name, and email)

* must provide value

How did you hear about our consultation services?

* must provide value

CTSI brochure or advertisement

Own division or department

Other (please specify)

* must provide value

Please fill out the contact information below for the person you are referring:

First Name:

* must provide value

Last Name:

* must provide value

Degree(s):

* must provide value

Department and Division (e.g. Medicine-Cardiology; School of Public Health-Epidemiology; Pediatrics-General Pediatrics)

* must provide value

Institution:

* must provide value

Cedars-Sinai

Charles R. Drew University

UCLA-Westwood

Lundquist Institute (Harbor-UCLA)

Other

West LA VA

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Academic Title:

* must provide value

Postdoc or Fellow

Clinical Instructor (if not trainee)

Assistant Professor

Associate Professor

Professor

Other

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Are you an "EARLY STAGE INVESTIGATOR" as defined by NIH?

Definition: A Program Director / Principal Investigator (PD/PI) who has completed their terminal research degree or end of post-graduate clinical training, whichever date is later, within the past 10 years and who has not previously competed successfully as PD/PI for a substantial NIH independent research award. A list of NIH grants that a PD/PI can hold and still be considered an ESI can be found here (https://grants.nih.gov/policy/early-investigators/list-smaller-grants.htm).

Yes

Don't Know

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Are you a "NEW INVESTIGATOR" as defined by NIH?

Definition: An investigator who has not previously received substantial, independent funding from NIH.

Yes

Don't Know

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The questions below are presented once to survey respondent depending on referral type.

What type of consultation are you requesting? (Check One)

To learn more about the 3 consultation services we offer, please visit:
https://www.ctsi.ucla.edu/researcher-resources/pages/specialpop

* must provide value

Internal Pre-submission Grant Review

Career Consultation

Project-Specific Consultation

I am not sure which consultation is most appropriate and I would like to speak with someone from your program.

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What type of consultation are you recommending for Dr. ______?

To learn more about the 3 consultation services we offer, please visit:
https://www.ctsi.ucla.edu/researcher-resources/pages/specialpop

* must provide value

Internal Pre-submission Grant Review

Career Consultation

Project-Specific Consultation

I am not sure which consultation is most appropriate.

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For FAQs regarding our grant studios (including eligibility), please visit:
https://www.ctsi.ucla.edu/pages/specialpop_faqs

Which special population does your research project involve? (Check all that apply)

NOTE: Health disparities is defined as differences in health status that occur due to gender, race or ethnicity, sexual orientation, gender identity, education or income, disability or functional impairment, or geographic location, or the combination of any of these factors.

* must provide value

Children (e.g. infant to age 18)

Older Adults

Population affected by health disparities (e.g., African Americans, Native Americans, Latinos, LGBTQ, rural populations or populations with low socioeconomic status)

Which special population does your grant involve? (Check all that apply)

NOTE: Health disparities is defined as differences in health status that occur due to gender, race or ethnicity, sexual orientation, gender identity, education or income, disability or functional impairment, or geographic location, or the combination of any of these factors.

* must provide value

Children (infant to age 18)

Older Adults

Population affected by health disparities (e.g., African Americans, Native Americans, Latinos, LGBTQ, rural populations or populations with low socioeconomic status)

Population with disparities (please specify):

* must provide value

Briefly describe your health specialty/research focus:

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Which special population does Dr. ______'s research project involve (please check all that apply):

NOTE: Health disparities is defined as differences in health status that occur due to gender, race or ethnicity, sexual orientation, gender identity, education or income, disability or functional impairment, or geographic location, or the combination of any of these factors.

* must provide value

Children (e.g. infant to age 18)

Older Adults

Population affected by health disparities (e.g., African Americans, Native Americans, Latinos, LGBTQ, rural populations or populations with low socioeconomic status)

Which special population does Dr. ______'s grant involve (please check all that apply):

* must provide value

Children (e.g. infant to age 18)

Older Adults

Population affected by health disparities (e.g., African Americans, Native Americans, Latinos, LGBTQ, rural populations or populations with low socioeconomic status)

Population with disparities (please specify):

* must provide value

Briefly describe Dr. ______'s health specialty/research focus:

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Briefly tell us why you are recommending Dr. ______ as a potential client:

* must provide value

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Please provide details of your grant application:

Please provide details of Dr. ______'s grant application:

Funding Opportunity Announcement (FOA)

* must provide value

Funding Opportunity Announcement (FOA)

* must provide value

Check One

* must provide value

New Submission

Resubmission (if resubmission, what was the previous score and percentile?)

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Check One:

* must provide value

New Submission

Resubmisssion (if resubmission, what was the previous score and percentile?)

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Previous score and percentile:

* must provide value

Previous score and percentile:

* must provide value

NIH Funding Agency (e.g. NIA, NIDDK, NIMH) or other (DoD, RWJF)

* must provide value

NIH Funding Agency (e.g. NIA, NIDDK, NIMH) or other (DoD, RWJF)

* must provide value

Grant Mechanism (e.g. K08, K23, R21, R01)

* must provide value

Grant Mechanism (e.g. K08, K23, R21, R01):

* must provide value

Target Submission Date:

* must provide value

M-D-Y

Target Submission Date:

* must provide value

M-D-Y

Mentor(s) and/or Collaborator(s):

* must provide value

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Mentor(s) and/or Collaborator(s):

* must provide value

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Project Title:

* must provide value

Project Title:

* must provide value

Grant Proposal Keywords

Have you discussed this grant with a NIH program officer or been invited to submit (DoD)?

Yes

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Please suggest potential reviewers:

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Approximate date when you may have a draft of Specific Aims and Research Strategy to share with reviewers

* must provide value

M-D-Y

Please answer the following 4 questions about your grant application:

Please answer the following 4 questions about grant application:

Does the study involve human subjects?

* must provide value

Yes

I don't know

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Does the study involve human subjects?

* must provide value

Yes

I don't know

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Are the participants prospectively assigned to an intervention?

* must provide value

Yes

I don't know

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Are the participants prospectively assigned to an intervention?

* must provide value

Yes

I don't know

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Is the study designed to evaluate the effect of the intervention on the participants?

* must provide value

Yes

I don't know

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Is the study designed to evaluate the effect of the intervention on the participants?

* must provide value

Yes

I don't know

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Is the effect that will be evaluated a health-related biomedical or behavioral outcome?

* must provide value

Yes

I don't know

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Is the effect that will be evaluated a health-related biomedical or behavioral outcome?

* must provide value

Yes

I don't know

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OPTIONAL: If you have any questions about our grant studios or would like to share additional information that would be helpful in coordinating your grant studio, please include here:

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OPTIONAL: If you have any questions about our grant studios or would like to share additional information that would be helpful in coordinating Dr. ______'s grant studio, please include here:

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How many hours per week can you commit to research in the next year?

Briefly, what is your projected plan in the next year regarding grant submissions, manuscripts in preparation, and/or data presentations at conferences (if applicable)?

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Briefly, describe your career goals in the next 5 years?

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What specific questions do you need consultation about?

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Please suggest potential faculty consultant(s) who we should consider asking to participate in the meeting:

What specific questions does Dr. ______ need consultation about?

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Please suggest potential faculty consultant(s) who we should consider asking to participate in the meeting:

What specific questions do you need consultation about?

* must provide value

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Please suggest potential faculty consultant(s) who we should consider asking to participate in the meeting:

What specific questions does Dr. ______ need consultation about?

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Please suggest potential faculty consultant(s) who we should consider asking to participate in the meeting:

Can we contact Dr. ______?

* must provide value

Yes

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REQUIRED: Please upload your CV here:

* must provide value

Upload file

Optional: Upload other project document (e.g. description of your project, Specific Aims, NIH summary statement, etc).

Upload file

If available, please upload your Specific Aims (NIH) or pre-proposal (DoD) here:

Upload file

If available, please upload Dr. ______'s CV here:

Upload file

If available, please upload Dr. ______'s Specific Aims (NIH) or pre-proposal (DoD) here:

Upload file

You indicated this is a resubmission. If available, please upload the NIH summary statement here:

Upload file

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.