Community Based Research Intake Form

If you are interested in having a research project completed by faculty at one of the PICCE institutions, please fill out the form below.

Organization

Contact Persion

Email Address

Phone Number

Project Title

Project Description

Project Discipline Project Discipline

Click "Add" to add additional research questions.

Question

Potential Data Sources

Have data

Need data

Unsure

Scope of research

Local

Regional

National

Planned use

Advocacy

Evaluation/reporting

Grant/funding development

Presentations

Publications

OtherOther

Resources available

Funding for faculty

Staff time

OtherOther

Desired start date

Desired completion date