Research Grant and Support Request | US

Investigator Initiated Studies (IIS) Grant Request

Thank you for contacting us about your interest in conducting research. Please complete the requested information below, which will help us review and evaluate your proposal. Include any additional material you feel will support this request.

A current copy of your Curriculum Vitae (CV) or resume must accompany the request.

Please provide a synopsis of your research proposal which must include the following information:

If a protocol has already been written, it may be included with the submission.

Attach your CV or Resume: * Required

Attachments more than 20 MB may have trouble transmitting successfully. If your total attachments size is greater than 20 MB, please contact rdg.clinical.research@teleflex.com

Attach your Proposal/Synopsis: * Required

Date * Required

Investigator Name * Required

Investigator Title * Required

Requester Name (if different from PI)

Requester Title (if different from PI)

Institution Name * Required

Address * Required

Country * Required

Phone Number:* Required

E-mail Address * Required

Associated Teleflex Product* Required

Research Title

Research Type

Number of Centers * Required

Research Proposal

Number of subjects anticipated * Required

Anticipated duration of the study, including follow-up (if applicable), and anticipated start date (if known)* Required

Type of Support Required

Please indicate the type of support required (click all that apply) * Required

Monetary (must attach a detailed budget with estimated amount)

Teleflex Product (must attach estimated quantity)

Other

Plans for Publication

Please indicate your plans for publication* Required

Attach Additional Documents: (i.e. detailed budget, publications, approvals)