{"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":"2021-06-07T16:07:20","modified_gmt":"2021-06-07T20:07:20","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":6,"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/pages\/309\/revisions"}],"predecessor-version":[{"id":406,"href":"https:\/\/www.purdue.edu\/hhs\/nutr\/crc\/wp-json\/wp\/v2\/pages\/309\/revisions\/406"}],"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}]}}