Preliminary review form - Impulse Dynamics

Preliminary Review

Organization Information:

Requestors Name:(Required)

Affiliated Organization:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Request Information:

Study Proposal Title:(Required)

Study Description

Study background/objective(Required)

Hypothesis(Required)

Study design (include patient eligibility criteria and endpoints to be collected)(Required)

Sample Size(Required)

Number of sites(Required)

Expected Duration of Study:(Required)

Amount of funding requested:(Required)

Is product requested?

Yes

No

Product name(Required)

Quantity(Required)

Have you or your organization previously applied for funding from the Company?:(Required)

Name of Impulse Dynamics Contact:

Or name of contact who referred you to this site, if applicable

Upload Documents:

Upload Principle Investigators Curriculum Vitae

Max. file size: 24 MB.

Upload study protocol or synopsis (optional)

Max. file size: 24 MB.

* A Detailed Study Protocol may include: • The project title • Expected duration of study • Project objectives or hypothesis • An explanation of the rationale and scientific novelty • The methods of study/study design and justification • A statistical analysis plan, including sample size justification and, where appropriate, a power analysis • A plan for handling adverse events and a risk/benefit analysis • A list of products involved (if specific) • References • Detailed publication plans

Line-item budget for study (optional)

Drop files here or

Max. file size: 24 MB, Max. files: 5.

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