New study request form

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Please complete this form to request for a new study to be set up in COINS.

Principal Investigator First and Last Name *

Principal Investigator E-mail Address *

Co-Investigator Name

Would you like a PI proxy set up for this study in COINS? If yes, please provide name and email address.

PI proxy will have permissions to add/remove users from your study and change study staff permissions. PI proxy must be listed as an approved investigator for the study with the IRB. Please list name and email address.

Study Name *

What would you like your COINS study name to be? (must be 12 characters or less, lower case alpha only)

IRB Number *

From IRB Approval Letter (example format: XX-XXX or xxxxx)

IRB of Record *

ex: OIRB, HRRC, WIRB

IRB Title *

Please copy directly from IRB Approval Letter

IRB Approval Date *

From IRB Approval Letter – Format: MM/DD/YYYY

IRB Expiration Date *

From IRB Approval Letter – Format: MM/DD/YYYY

Estimated Study Start Date

Date that you would like to enroll your first participant. Format MM/DD/YYYY

Estimated Study End Date

Date that you would expect to close your study with the IRB. Format: MM/DD/YYYY

Total Number of Approved Study Participants to Enroll *

Number of URSIs needed for this study

Is the study considered a clinical trial per the NIH definition? *

https://grants.nih.gov/policy/clinical-trials/definition.htm If the study is a clinical trial, the study will need to be registered on ClinicalTrials.gov and all investigators with access to the study need to have GCP training on file at MRN.

Yes

Other:

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