Inquiry Form

To initiate research involvement with the CRN, please complete the following form.

Required fields are marked with an asterisk ( * ).

* Your first name:
Your middle initial:
* Your last name:
Your credential(s): (hold CTRL while clicking to select multiple options)	Other:
* Your e-mail address:
	Send a carbon copy of this message to yourself
Are you in the vicinity of a CRN site? (Your inquiry will be forwarded to your local site's collaboration coordinator, or to the CRN Executive Committee if not.)
Are you a National Institutes of Health Colleague? (If so, your inquiry will be copied to Martin Brown, PhD, NCI's CRN Program Officer.)	Yes No
* Your job title:
* Your institution:	Other:
* Your current or past collaborations with CRN projects and/or investigators:
* Your research interests: (hold CTRL while clicking to select multiple options)	Other:

If you have a specific project proposal:

A brief description of the project team:
A statement of the main hypothesis/research question(s):
Nature of the data required -- automated data, chart review, survey, etc.:
Estimated timeline to develop and submit proposal:
Funding agency:	Other:
Funding mechanism:	Other: (Please do not type in this field)

Once a collaboration is established, the CRN PI office will ask you to complete the Collaboration Evaluation Survey.

Map of CRN sites: