{"id":309,"date":"2020-07-27T15:28:50","date_gmt":"2020-07-27T19:28:50","guid":{"rendered":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/?page_id=309"},"modified":"2026-07-22T08:46:53","modified_gmt":"2026-07-22T12:46:53","slug":"consult-form","status":"publish","type":"page","link":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/consult-form\/","title":{"rendered":"Consult Form"},"content":{"rendered":"\n\t\t<h2>\n\t\t\tConsult Form \n\t\t<\/h2>\n                \n                            <h3 class=\"gform_title\">Purdue University &#8211; Clinical Research Center (PU-CRC): Protocol Review 2021<\/h3>\n                        <ul id=\"gform_fields_2\" class=\"gform_fields top_label form_sublabel_below description_below\"><li id=\"field_2_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"><\/li><li id=\"field_2_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_2\">Protocol Title*<\/label><\/li><li id=\"field_2_3\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_3\">IU Protocol #\/Purdue CRC Protocol #<\/label><\/li><li id=\"field_2_4\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_4\">Funding Source (name)<\/label><\/li><li id=\"field_2_5\" class=\"gfield gf_list_inline field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\">If known, include funding agency and # Status (select one)<\/label><ul class=\"gfield_radio\" id=\"input_2_5\"><li class=\"gchoice_2_5_0\"><label for=\"choice_2_5_0\" id=\"label_2_5_0\">To Be Submitted<\/label><\/li><li class=\"gchoice_2_5_1\"><label for=\"choice_2_5_1\" id=\"label_2_5_1\">Submitted<\/label><\/li><li class=\"gchoice_2_5_2\"><label for=\"choice_2_5_2\" id=\"label_2_5_2\">Funded<\/label><\/li><\/ul><\/li><li id=\"field_2_40\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_40\">Funding Dates<\/label><\/li><li id=\"field_2_41\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_41\">Expected Project Start Date<\/label>\n                            \n                            Date Format: MM slash DD slash YYYY\n                        <\/li><li id=\"field_2_9\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_9\">IRB #<\/label><\/li><li id=\"field_2_10\" class=\"gfield gf_list_inline field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\">IRB Status (select one)<\/label><ul class=\"gfield_radio\" id=\"input_2_10\"><li class=\"gchoice_2_10_0\"><label for=\"choice_2_10_0\" id=\"label_2_10_0\">To Be Submitted<\/label><\/li><li class=\"gchoice_2_10_1\"><label for=\"choice_2_10_1\" id=\"label_2_10_1\">Pending<\/label><\/li><li class=\"gchoice_2_10_2\"><label for=\"choice_2_10_2\" id=\"label_2_10_2\">Approved<\/label><\/li><li class=\"gchoice_2_10_3\"><label for=\"choice_2_10_3\" id=\"label_2_10_3\">Amended<\/label><\/li><\/ul><\/li><li id=\"field_2_11\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_11\">Date of Approval<\/label>\n                            \n                            Date Format: MM slash DD slash YYYY\n                        <\/li><li id=\"field_2_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label gfield_label_before_complex\">Primary Investigator*<\/label>\n                                                    \n                                                    <label for=\"input_2_12_3\">First<\/label>\n                                                    \n                                                    <label for=\"input_2_12_6\">Last<\/label>\n                        <\/li><li id=\"field_2_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_13\">Department<\/label><\/li><li id=\"field_2_14\" class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_14\">Email*<\/label>\n                            \n                        <\/li><li id=\"field_2_15\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_15\">Phone<\/label><\/li><li id=\"field_2_16\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_16\">Lab Staff Working on Project<\/label><textarea name=\"input_16\" id=\"input_2_16\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label gfield_label_before_complex\">Primary Contact<\/label>\n                                                    \n                                                    <label for=\"input_2_17_3\">First<\/label>\n                                                    \n                                                    <label for=\"input_2_17_6\">Last<\/label>\n                        <\/li><li id=\"field_2_18\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_18\">Primary Contact Email<\/label>\n                            \n                        <\/li><li id=\"field_2_19\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_19\">Primary Contact Phone<\/label><\/li><li id=\"field_2_22\" class=\"gfield gf_list_3col field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\">Bionutrition Services<\/label><ul class=\"gfield_checkbox\" id=\"input_2_22\"><li class=\"gchoice_2_22_1\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_1\" id=\"label_2_22_1\">Study Manager<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_2\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_2\" id=\"label_2_22_2\">Isocaloric Gram Weight Menu Development<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_3\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_3\" id=\"label_2_22_3\">Acute Test Meal menu Development<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_4\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_4\" id=\"label_2_22_4\">Homogenates<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_5\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_5\" id=\"label_2_22_5\">Acute Test Meal Tray<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_6\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_6\" id=\"label_2_22_6\">Full Service Snack<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_7\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_7\" id=\"label_2_22_7\">Fully Prepared Gram Weighed Meal<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_8\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_8\" id=\"label_2_22_8\">Pack out Gram Weighed Raw Ingredients<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_9\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_9\" id=\"label_2_22_9\">Protocol Management<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_11\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_11\" id=\"label_2_22_11\">Remote Studies<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_12\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_12\" id=\"label_2_22_12\">Consulting &#8211; Bionutrition Manager\/RD<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_22_13\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_22_13\" id=\"label_2_22_13\">Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/li><li id=\"field_2_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_24\">If other, please explain<\/label><\/li><li id=\"field_2_30\" class=\"gfield gf_list_3col field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\">Clinical Services<\/label><ul class=\"gfield_checkbox\" id=\"input_2_30\"><li class=\"gchoice_2_30_1\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_30_1\" id=\"label_2_30_1\">DXA<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_30_2\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_30_2\" id=\"label_2_30_2\">Anthropometrics<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_30_3\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_30_3\" id=\"label_2_30_3\">Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/li><li id=\"field_2_33\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_33\">If other, please list<\/label><\/li><li id=\"field_2_31\" class=\"gfield gf_list_3col field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\">Anthropometrics<\/label><ul class=\"gfield_checkbox\" id=\"input_2_31\"><li class=\"gchoice_2_31_1\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_31_1\" id=\"label_2_31_1\">Weight<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_31_2\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_31_2\" id=\"label_2_31_2\">Height<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_31_3\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_31_3\" id=\"label_2_31_3\">Waist Circumference<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_31_4\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_31_4\" id=\"label_2_31_4\">Waist to Hip<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_31_5\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_31_5\" id=\"label_2_31_5\">Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/li><li id=\"field_2_32\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_32\">If other, please list<\/label><\/li><li id=\"field_2_35\" class=\"gfield gf_list_3col field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\">Diet Assessment Services<\/label><ul class=\"gfield_checkbox\" id=\"input_2_35\"><li class=\"gchoice_2_35_1\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_1\" id=\"label_2_35_1\">Dietary Recall &#8211; Standard Recall<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_2\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_2\" id=\"label_2_35_2\">Dietary Recall &#8211; Comprehensive Recall<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_3\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_3\" id=\"label_2_35_3\">Dietary Recall &#8211; Comprehensive Recall w\/supplements<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_4\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_4\" id=\"label_2_35_4\">Dietary Record Standard<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_5\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_5\" id=\"label_2_35_5\">Dietary Record Comprehensive<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_6\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_6\" id=\"label_2_35_6\">Mailing to participant<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_7\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_7\" id=\"label_2_35_7\">Consulting &#8211; RD<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_8\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_8\" id=\"label_2_35_8\">Consulting &#8211; Faculty Diet Assessment<\/label>\n\t\t\t\t\t\t\t<\/li><li class=\"gchoice_2_35_9\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<label for=\"choice_2_35_9\" id=\"label_2_35_9\">Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/li><li id=\"field_2_36\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_36\">If other, please list<\/label><\/li><li id=\"field_2_42\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_42\">Additional Comments<\/label><\/li><li id=\"field_2_43\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_43\">If known, please provide account number and project period:<\/label><\/li><li id=\"field_2_45\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"><\/li><li id=\"field_2_44\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_44\">Clinical Estimate<\/label><textarea name=\"input_44\" id=\"input_2_44\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_46\">Bionutrition Estimate<\/label><textarea name=\"input_46\" id=\"input_2_46\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_47\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_47\">Diet Assessment estimate<\/label><textarea name=\"input_47\" id=\"input_2_47\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_48\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_48\">Proposed Meeting Date to discuss form submission with CRC Staff:<\/label>\n                            \n                            Date Format: MM slash DD slash YYYY\n                        <\/li><li id=\"field_2_49\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"><\/li><li id=\"field_2_50\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_50\">Clinical Budget:<\/label><textarea name=\"input_50\" id=\"input_2_50\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_51\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_51\">Bionutrition Budget:<\/label><textarea name=\"input_51\" id=\"input_2_51\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_52\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_52\">Diet Assessment Budget:<\/label><textarea name=\"input_52\" id=\"input_2_52\" class=\"textarea medium\" rows=\"10\" cols=\"50\"><\/textarea><\/li><li id=\"field_2_53\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_53\">CRC Staff Member Signature:<\/label><\/li><li id=\"field_2_56\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_56\">Date<\/label>\n                            \n                            Date Format: MM slash DD slash YYYY\n                        <\/li><li id=\"field_2_54\" class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_54\">PI Signature:<\/label><\/li><li id=\"field_2_57\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_57\">Date<\/label>\n                            \n                            Date Format: MM slash DD slash YYYY\n                        <\/li><li id=\"field_2_55\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_55\">CRC Director Signature:<\/label><\/li><li id=\"field_2_58\" class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"><label class=\"gfield_label\" for=\"input_2_58\">Date<\/label>\n                            \n                            Date Format: MM slash DD slash YYYY\n                        <\/li>\n                            <\/ul>\n          \n            \n            \n            \n            \n            \n            \n            \n                        \n                \n","protected":false},"excerpt":{"rendered":"<p>Consult Form Purdue University &#8211; 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 Date Format: MM slash DD slash YYYY IRB # IRB Status&hellip;<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-309","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/pages\/309","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/comments?post=309"}],"version-history":[{"count":7,"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/pages\/309\/revisions"}],"predecessor-version":[{"id":491,"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/pages\/309\/revisions\/491"}],"wp:attachment":[{"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/media?parent=309"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}