Research Intake Form Question Title * 1. Contact Information Name of Principal Investigator (PI) Project Contact (person responsible for project communications, if different than above) Name of Institution Mailing Address Phone Number Email Address Fax Number Question Title * 2. Research Project Purpose of Project Research Question Length of Study Funding Sources for Study Intended Use of Results Investigator's Names and Credentials (#1) Investigator's Names and Credentials (#2) Investigator's Names and Credentials (#3) IRB Approval Date and Number, or Proof of Exemption (attach documentation in #3 below, if applicable) Question Title * 3. Supporting Documentation (IRB documentation, abstract, protocol, survey, and other relevant documents) DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Supporting Documentation (IRB documentation, abstract, protocol, survey, and other relevant documents) Question Title * 4. Human Milk Needed Yes No Other (Please specify) Question Title * 5. Human Milk Information Volume Required Container Requirements Pumping or Screening Dates Requirements Question Title * 6. Type of Milk Needed Preterm Yes No Preterm menu Term Yes No Term menu Colostrum Yes No Colostrum menu Pooled Donor Yes No Pooled Donor menu Single Donor Yes No Single Donor menu Pasteurized Yes No Pasteurized menu Raw Yes No Raw menu Frozen Yes No Frozen menu Fresh Yes No Fresh menu Medication Okay Yes No Medication Okay menu If medications are not okay, please explain. Question Title * 7. Documentation (Please note: Milk banks are unable to provide patient identifiers and protected health information.) Donor Demographics Required Yes No Donor Demographics Required menu Blood Test Results Required Yes No Blood Test Results Required menu Other (please specify) Question Title * 8. Additional Supporting Documentation DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Additional Supporting Documentation Question Title * 9. Research Agreement (Choose all that apply) I am conducting research that increases understanding of human milk's unique properties and/or its appropriateness for specific medical conditions or populations. I am conducting a survey/qualitative/epidemiological enquiry related to human milk and/or human milk banking. I am not conducting research that strives to create a substitute for human milk. My research is not funded by an organization that produces a substitute for human milk. I agree to pay the processing fee charged by the milk bank supplying milk for my research. I agree to acknowledge any relevant milk banks in publications pertaining to this study. I agree to be in compliance with the above policies. Question Title * 10. By writing my name below as a virtual signature and submitting this survey, I agree that I am authorized to commit this project to full compliance with the above policies as much as relevant and possible. Done
