Panel Request Form

(*) denotes required field.
Please fill in "n/a" if not applicable.
What type of panel are you requesting?(*)

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PI Name:(*)
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Academic Title:(*)
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Email:(*)
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Degrees:(*)
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eRA Commons ID:(*)
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Institutional ID (i.e. Blazer ID):(*)
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Institution:(*)

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Please list institution if not listed above:
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School:(*)
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Department:(*)
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Division:(*)
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Project Title:(*)
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Type of Application (i.e. R01, R03, K08, K23, T32, U01):(*)
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Due Date:(*)
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Request for Application (RFA):(*)
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What other faculty co-investigators are involved in the project?
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Have you consulted with a biostatistician on the design of your study?(*)

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Manuscript Submission:(*)

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If yes, name of Journal?
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Does your application include the following:(*)
Please list any special populations:
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Reviewers I would like on my panel (provide names and email addresses):(*)
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Reviewers to exclude from my panel:(*)
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(*)
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