Emergency Medicine Research Division Universal Request Form

Date of Request (Please put in mm/dd/yyyy format) *

Requester Name *

Email Address *

Title of Request *

Services Sought * Grant submission (like NIH, state, foundation, UMMHC, UMass, Healy, pharma, etc.) UMass EM Research Fund application for internal funding support Statistical support IRB review or guidance OnCore guidance Implementation or CQI project guidance (e.g., EMPIRE consutlation) Volunteers Other

Briefly Describe Your Need *