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 DatesExpected Project Start Date IRB #IRB Status (select one) To Be Submitted Pending Approved Amended Date of Approval Date of Approval Primary Investigator* First Last DepartmentEmail* 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 explainClinical Services DXA Anthropometrics Other If other, please listAnthropometrics Weight Height Waist Circumference Waist to Hip Blood Draw Straight Stick Saline Lock IV IV Blood Draws Consulting Other If other, please listDiet 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 listAdditional CommentsIf 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.This field is hidden when viewing the formClinical EstimateThis field is hidden when viewing the formBionutrition EstimateThis field is hidden when viewing the formDiet Assessment EstimateThis field is hidden when viewing the formProposed Meeting Date to discuss form submission with CRC Staff: Final Approved Budgets:This field is hidden when viewing the formClinical BudgetThis field is hidden when viewing the formBionutrition BudgetThis field is hidden when viewing the formDiet Assessment BudgetThis field is hidden when viewing the formCRC Staff Member Signature:This field is hidden when viewing the formDate This field is hidden when viewing the formPI Signature:This field is hidden when viewing the formDate This field is hidden when viewing the formCRC Director Signature:This field is hidden when viewing the formDate
