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: Project Contact Name: Project Contact Phone: Project Contact Email: * 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. Project Abstract: DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File No file chosen Remove File Choose file for question 7 Project Abstract: Replace file for question 7 Project Abstract: Remove file for question 7 Project Abstract: * 8. Full Research Proposal * 9. Full Research Proposal: DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File No file chosen Remove File Choose file for question 9 Full Research Proposal: Replace file for question 9 Full Research Proposal: Remove file for question 9 Full Research Proposal: * 10. The requested support is needed by: Date * 11. Referred By: Academic Partner Community Member CERB Member SUBMIT YOUR PROJECT: We look forward to collaborating with you to empower our community!