Concept Sheet Submission Form Johns Hopkins Bloomberg 概表提交表格约翰斯霍普金斯彭博.docVIP

Multicenter AIDS Cohort Study / Womens Interagency HIV Study Collaboration Concept Sheet Submission Form Guidelines This form is intended for all MACS and/or WIHS collaborations, whether using data from both studies or from just one of the studies. Please fill out all the lettered and numbered sections below: (this form will not be accepted unless all of the fields are completed) A. GENERAL INFORMATION 1. Date of submission: 2. Lead Investigator(s): 3. Study Title: 4. Contact Person: (if different from lead investigator) 5. Submission type: Initial Revised Addendum/Expansion of previously approved Concept (Readme# _______) 6. Proposal includes: MACS WIHS MACS only WIHS only MACS local study only Other cohorts (identify): ____________________ 7. Guidelines (pages 8-11) have been reviewed: Yes No 8. Institution: Continue on next page ? Internal Use Only - DO NOT REMOVE Keep on Page 1 CAMACS Use Only MACS EC Date: __________________________________ MACS Readme#: r________ ____ Approved ____ Approved for grant submission ____ Approved w/comment ____ Revision Requested ____ Rejected ____ Approved by _____________________ Working Group ____ Deferred WDMAC Use Only SUB date: LLS?: REV PDR end: DIST date: PIR: PDR: PIR end: LAB: GEN: OTCM: 1 2 3 4 A. GENERAL INFORMATION (cont) 9. Address: 10. Telephone Number: 11. FAX Number: 12. Email: 13. Topic(s): Please choose from the following topics: Behavioral, Biomarkers, Cancer/Pathology, Cardiovascular, Clinical/Epidemiology, Coinfections, Disease Progression, Genomics/Genetics, Hepatitis/Liver, HPV, Laboratory, Metabolics, Methodological, Neurocognition/Neuropsychological, Pathogenesis/Immunology, Treatment Response 14. Sites involved in the proposed study: All MACS WIHS sites  All MACS sites: Baltimore/District of Columbia Chicago Los Angeles