Research Project Application

Please fill out thoroughly for your research project to be considered.

Complete all fields; if they do not apply mark with N/A. You will be contacted within five business days of receipt with a preliminary response with guidance on the next steps in the review and acceptance process.

Principal Investigator (PI) Information

Name*

First Name* Last Name*

Position/Title*

Area of Expertise/Research Interest*

Name of Research Entity*

Address*

Street Address * Address Line 2 City * State / Region * ZIP / Postal Code * Country *

Phone*

Fax:*

Website

Please note, the entire website address is required, including the pre-fix of http:// or https://.

Email*

Biospecimen Delivery Receiver and Location

Name

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Project Information

Project Title

Description/Public Health Relevance Statement

Do you currently have funding for this project?

Yes

Will you require a letter of support for your funding?

Yes

What is your primary source of funding for this work?

Name any additional sources of funding for this work

Is there an IRB approval process requirement?

Yes

Existing IRB Number

If not applicable, please mark NA.

Will you require a non-disclosure agreement related to research specifics?

Yes

Estimated Duration of Study

Please tell us briefly what resources your project requires, including data, non-transplantable organs and/or tissue or other resource. Please be specific in your description.

Acknowledgement*

I agree.

In submitting this application, the submitter hereby agrees to acknowledge the support of LifeLink Foundation and generosity of organ and tissue donors and their families in making possible the study or project’s success and shall agree to state such an acknowledgment in any publication, presentation, abstract, grant application or poster resulting from this support.