IIT LOI Application

Title of LOI *

Study Phase *

Study Drug(s)

Name of Study Drug(s) *

Have you discussed this concept with the company that manufactures the Study Drug? *

Yes

No

If YES, please indicate name of company and contact information of company representative

IND Exempt *

Yes

No

Unknown

Contact Information

Proposing PI *

Mentored PI

Cell Phone *

Email *

Street Address *

Country *

State / Province *

City *

Zip / Postal Code

Conflict of Interest

Potential Conflict of Interest? *

None of the proposed study chairs or co-chairs have a potential conflict of interest

A conflict of interest may exist. (Provide name of individual and brief summary of conflict)

Conflict of Interest Summary

Clinical Research

Hypothesis and Study Objectives (200 Words Max) *

Brief Study Synopsis *

Translational Research

Does this proposal include a translational research component? *

Yes

No

Translational Research Hypothesis and Objectives (500 Words Max)

Specimen Requirements

Specimen Shipping/Storage

Type of Testing

Translational Research Collaborator

Funding Status

Anticipated Budget (Describe an anticipated budget and overview of plan to secure funds to cover clinical trial expenses) *

Has the concept been submitted for external support? *

Yes, specifyYes, specify

No

If Yes, has the external support been granted?

Yes, specify amountYes, specify amount

No

If No, describe external support commitment known:

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