What kind of support does your project require from CORE? *

(Please tick all that apply):

Clinical database with CRF's (ALEA)

Data management

Drug supply management (ALEA)

ePRO (ALEA)

Funding application advice

Randomisation (ALEA)

Statistics support

Writing protocol assistance

Database validation

Translation of ePRO required? *

Yes

No

Not applicable

Is this part of your PhD or other qualification? *

Yes

No

Are you or is this study in any way affiliated with or funded by the UHS BRC? *

Yes

No

Please tell us what organisation you are from?

University of Southampton

NHS Trust (please specify below)

BRC

Clinical Trials Unit

Other (please specify below)

Name *

First Name

Last Name

Is the Chief Investigator the same as the above?

Yes

No (please complete the below)

Do you already have funding for this proposal?

Yes

No

Have you identified a potential funding body?

(e.g. HTA, CRC)

Yes

No

Deadline for application

(If applicable)

MM

DD

YYYY

If your grant has been successful, what organisation is holding your funds?

NHS Trust (please specify below)

University of Southampton (please provide the grant code below)

Observational

Interventional

Phase I

Phase II

Phase III

Phase IV

Proposed start date

What is your proposed start date

MM

DD

YYYY