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 signed and dated 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 Protocol/Synopsis: * Required

Date * Required

Investigator's Name * Required

Investigator's Credentials * Required

Requester Name (if different from PI)

Institution Name * Required

Address (Institution Address, City, State/Province) * Required

Country * Required

Contact Phone Number * Required

Contact E-mail Address * Required

Associated Teleflex Product * Required

Research Title

Care Setting * 1 Required

Research Type

Number of Centers * Required

Research Proposal

Research Proposal and Objective * Required

Number of subjects anticipated * Required

Duration of Research * 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

Funding

Teleflex Product(s)

Other (specify)

Plans for Publication

Publication Goals and Timeline * Required

Ethics Committee/Institutional Review Boards/IACUC Submission Plan * Required

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