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* 1. Contact Information

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* 2. Project/study title

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* 3. What phase is your project/study in?

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* 4. What purpose would the Community Engagement studio serve for your team? (check all that apply)

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* 5. Abstract: provide a 250 word summary noting the project/study aims and the problem the research will address.

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* 6. What is the geographic focus of this project/study? (e.g. statewide, county specific, etc.)

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* 7. What is the population of interest for this project/study? For example, is the project geared toward people of a certain age, race/ethnicity, diagnosis, or income (e.g. Hispanic men, pregnant women, diabetics patients, etc)? If known, what are the eligibility requirements for participation?

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* 8. How long are participants expected to engage in this project/study?

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* 9. How is the project or intervention being implemented?

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* 10. What would you like community feedback on? Is there a specific community perspective you are looking for?

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