Consult Form Purdue University - Clinical Research Center (PU-CRC): Protocol Review 2021 Protocol Title* IU Protocol #/Purdue CRC Protocol # Funding Source (name) If known, include funding agency and # Status (select one) To Be Submitted Submitted Funded Funding Dates Expected Project Start Date MM slash DD slash YYYY IRB # IRB Status (select one) To Be Submitted Pending Approved Amended Date of Approval MM slash DD slash YYYY Date of Approval MM slash DD slash YYYY Primary Investigator* First Last Department Email* PhoneLab Staff Working on ProjectPrimary Contact First Last Primary Contact Email Primary Contact PhoneBionutrition Services Study Manager Isocaloric Gram Weight Menu Development Acute Test Meal Menu Development Homogenates Acute Test Meal Tray Full Service Snack Fully Prepared Gram Weighed Meal Pack out Gram Weighed Raw Ingredients Protocol Management Remote Studies Consulting - Bionutrition Manager/RD Other If other, please explain Clinical Services DXA Anthropometrics Other If other, please list Anthropometrics Weight Height Waist Circumference Waist to Hip Blood Draw Straight Stick Saline Lock IV IV Blood Draws Consulting Other If other, please list Diet Assessment Services Dietary Recall - Standard Recall Dietary Recall - Comprehensive Recall Dietary Recall - Comprehensive Recall w/supplements Dietary Record Standard Dietary Record Comprehensive Mailing to participant Consulting - RD Consulting - Faculty Diet Assessment Other If other, please list Additional Comments If known, please provide account number and project period: Budget estimates to be completed by CRC Staff – NOTE BEST PRACTICES ARE TO WORK WITH THE CRC TO OBTAIN COST ESTIMATES PRIOR TO SUBMISSION OF THE PROPOSAL.HiddenClinical Estimate HiddenBionutrition Estimate HiddenDiet Assessment Estimate HiddenProposed Meeting Date to discuss form submission with CRC Staff: MM slash DD slash YYYY Final Approved Budgets:HiddenClinical Budget HiddenBionutrition Budget HiddenDiet Assessment Budget HiddenCRC Staff Member Signature: HiddenDate MM slash DD slash YYYY HiddenPI Signature: HiddenDate MM slash DD slash YYYY HiddenCRC Director Signature: HiddenDate MM slash DD slash YYYY
