EXIT Exit CERB Intake Form CERB Support Intake Form Completion of this form will help facilitate your request. * 1. Project Name: (please provide both the full study title (descriptive) and the working study title * 2. PI contact information: Name: Email: Institution Affiliation: Department: Phone: * 3. What is the category of your proposal/project? Special projects Full RFA Other (please specify) * 4. What is the status of your proposal/project? Pre-submission/writing Pre IRB approval Submitted unfunded Funded/pre-implementation Implemented * 5. What level of support are you seeking, from the CERB? (Check all that apply) Community Ethics review and critique of proposal Letter of Endorsement Suggestions for enhancing the community engagement component Serving as the project's Community Advisory Board Other (please specify) * 6. Project Abstract: * 7. Full Research Proposal * 8. The requested support is needed by: Date MM / DD / YYYY We look forward to collaborating with you to empower our community!