Request for Biostatistical Support
Department of Pediatrics
Icahn School of Medicine at Mount Sinai

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* 1. Investigator Name:

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* 2. Investigator Level (medical student, resident, fellow, faculty (rank), other):

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* 3. Contact Information

Email Address

Phone Number

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* 4. Pediatric Division

Other (please specify)

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* 5. Faculty mentor (trainees):

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* 6. Project Title:

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* 7. Please attach a 1-2 page summary of the project, including specific aims, and any information about the biostatistical support requested.

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* 8. Support requested:

Study preparation and/or pre-study planning

Sample size, power calculations, and analytic plans

Quality improvement science tests

Database management

Standard statistical analyses (chi-square tests, t-tests, regressions, non-parametric tests)

Additional analyses (please describe)

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* 9. What are the analyses for?

PAS abstract

Other abstract (if you check this box, please state which meeting in the comment box in question #7)

PAS presentation

Other presentation (if you check this box, please state which meeting in the comment box in question #7)

Extramural peer-reviewed grant funded by NIH

Extramural peer-reviewed grant funded by other organization (if you check this box, please state which funding agency in the comment box in question #7)

Manuscript in preparation

Manuscript revision

Other:

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* 10. Please fill out as requested in question #6

Other abstract:

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* 11. Due date:

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* 12. Do you have other grant funds that could support this biostatistical request?

Yes

If yes, please clarify:

**Please note that proposals received less than two months prior to PAS and NIH grant deadlines may not have time to be addressed.**

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* 13. Proposal has been reviewed and approved by (will need to confirm approval below):

SOC

FAC

Quality and Safety Leadership

Division Chief or research mentor

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* 14. By filling out each box below, you are confirming that you checked with the person listed and that they approve

Investigator:

Research/Faculty mentor (trainees):

Approved by:

Please send an email to shana.schloss@mssm.edu after completing this form.

* The Department of Pediatrics should be acknowledged as providing support for your project *