Intent to Participate in a Clinical Trial

Instructions: To properly plan ahead for workflows and information gathering, please submit this form as a Notice of Intent to participate in Clinical Trials as soon as possible but No Later Than 20 Business Days before the anticipated start date.

Your Name (person submitting this intent form):
Title of Clinical Trial
Anticipated Start Date Anticipated Start Date / MM / DD YYYY
Sponsor/Agency Name:
PI Name: PI Name: First Last
PI Phone PI Phone - ### - ### ####
PI Email
PI Department and Office Address:
Primary Place of Performance (physical address): Primary Place of Performance (physical address):
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Co-PI(s) Name(s) and Department(s) and Addresses:
Type:

Type: New Proposal Resubmission Modification
F&A waiver requested?

F&A waiver requested? Yes No
Flow through a second agency? (If yes, name the agency.)
Subcontractors or External Entities (please name):
Objective:

Objective: Research
Travel

Travel Yes No
If yes, to where?

If yes, to where? Domestic International Both
Please list the specific state(s) and/or countries to where you are traveling:
Comments and Budget Notes:
Space Information:
Is space available for this project?

Is space available for this project? No Yes: Specify building and room # Yes: Specify building and room #
Are space alternations requested?

Are space alternations requested? No Yes

Intent to Participate in a Clinical Trial

Intent to Participate in a Clinical Trial

Space Information: