<p> Center for Surgery and Public Health</p><p>Request for Biostatistical/Programming Services and Study Design Support</p><p>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.</p><p>Date of Request: Email Address:</p><p>Principal Investigator: Mailing Address:</p><p>Co-Investigators:</p><p>Project Title: </p><p>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.)</p><p>CSPH Member: YES NO (If no, indicate level of interest in CSPH.)</p><p>What type of service are you requesting? Please check all that apply.</p><p>Study Design Data Manipulation Data Analysis </p><p>Requested deliverables: (i.e. SAS program logs, SAS raw output, summary data tables; format type, etc.)</p><p>What is the purpose of your request? Please check all that apply.</p><p>Abstract Manuscript Grant Proposal</p><p>Please include deadline: ______</p><p>Requested Programming / Biostatistical support start date: ______Anticipated end date: ______</p><p>Have you been awarded funding to support biostat / programming for this research? YES NO</p><p>If yes: Please provide source of funding: ______Duration of funding: ______</p><p>If you seeking funding for this research, what is the source? </p><p>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.)</p><p>Page 1 Please complete the following information for your specific biostatistical / programming support request.</p><p>A. Overview of Project Methods and Analysis:</p><p>- Data source(s): - Study year(s) for requested analysis (if applicable): - Methods (modeling details/specifics):</p><p>B. Denominator Definition: (if applicable)</p><p>- Description of cohort study population:</p><p>C. Filtering Criteria (if applicable): </p><p>- Inclusion/Exclusion criteria:</p><p>D. Measures/Event (Numerator) Definition: (if applicable)</p><p>- Specific details of event/cohort (i.e. procedure codes):</p><p>E. Exposure/Outcomes Measures:</p><p>- Exposure/Intervention (independent variables):</p><p>- Covariates (i.e. age, sex, race, income):</p><p>- Outcomes (dependent variables): </p><p>Signature of PI: ______Date: ______</p><p>TO BE COMPLETED BY CSPH: Assigned Programmer: Requested Completion Date: Work Start Date: Actual Completion Date: </p><p>Page 2</p>