Molecular Markers in Blood and Gastrointestinal Tissues

Center for Surgery and Public Health

Request for Biostatistical/Programming Services and Study Design Support

Instructions: Please complete this form and submit it to Tammy Ballard at [email protected]. If you have any questions, Tammy can be reached at (617) 525-9846.

Date of Request: Email Address:

Principal Investigator: Mailing Address:

Co-Investigators:

Project Title:

Project Abstract/Goal(s) of Study: (In the space below, please provide an abstract of your research protocol and alignment with Center goals - 2-3 sentences.)

CSPH Member: YES NO (If no, indicate level of interest in CSPH.)

What type of service are you requesting? Please check all that apply.

Study Design Data Manipulation Data Analysis

Requested deliverables: (i.e. SAS program logs, SAS raw output, summary data tables; format type, etc.)

What is the purpose of your request? Please check all that apply.

Abstract Manuscript Grant Proposal

Please include deadline: ______

Requested Programming / Biostatistical support start date: ______Anticipated end date: ______

Have you been awarded funding to support biostat / programming for this research? YES NO

If yes: Please provide source of funding: ______Duration of funding: ______

If you seeking funding for this research, what is the source?

How does this research support the long term development of your research portfolio? (e.g. pilot study to support future grant application, establish working collaborations, etc.)

Please complete the following information for your specific biostatistical / programming support request.

A. Overview of Project Methods and Analysis:

- Data source(s): - Study year(s) for requested analysis (if applicable): - Methods (modeling details/specifics):

B. Denominator Definition: (if applicable)

- Description of cohort study population:

C. Filtering Criteria (if applicable):

- Inclusion/Exclusion criteria:

D. Measures/Event (Numerator) Definition: (if applicable)

- Specific details of event/cohort (i.e. procedure codes):

E. Exposure/Outcomes Measures:

- Exposure/Intervention (independent variables):

- Covariates (i.e. age, sex, race, income):

- Outcomes (dependent variables):

Signature of PI: ______Date: ______

TO BE COMPLETED BY CSPH: Assigned Programmer: Requested Completion Date: Work Start Date: Actual Completion Date: