####### ![](media/image1.bmp)**North Florida/South Georgia Veterans Health System**

**BRRC Request for Biostatistics Support**

***You will receive a response within 1 week of submitting this
completed form.***

**Submit form to James Korner, BRRC Deputy Dtr; 376-1611, X5246; Fax
271-4536; VA Box 151A**

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  **Project   
  Title:**    

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  --------------------- -------------------------------------------------
  **Principal           
  Investigator (PI):**  

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  ---------- ------------------- ----- ---------- ----------------------------
  **PI                                 **P.I.     
  Phone:**                             Email:**   

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+-------------+---------------------------+---+---------------------------+
| **Coinves   | 1\.                       |   | 3\.                       |
| tigators:** |                           |   |                           |
|             |                           |   |                           |
| (list up to |                           |   |                           |
| 4)          |                           |   |                           |
+-------------+---------------------------+---+---------------------------+
|             | 2\.                       |   | 4\.                       |
+-------------+---------------------------+---+---------------------------+

**Purpose (check one)** Only one request/project required:

  ---- -------------------- ---- ----------------- ---- -------------------
       Pilot Work                New Grant              Existing Grant

  ---- -------------------- ---- ----------------- ---- -------------------

Will this activity be funded by Core dollars? NO YES

[Will this activity be funded from a grant? NO YES Amount:
.]{.underline}

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  If YES,        
  Source:        

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**Period for which this support will be needed**:

  --------- ------------------ ----- -------- -----------------------------
  Start                              End      
  Date:                              Date:    

  --------- ------------------ ----- -------- -----------------------------

***To Be Completed by Samuel Wu, Director of Biostatistics Core***

+-----------------------------+--------------+---+---+---+------------------+---+
|                             |              |   |   | * |                  |   |
|                             |              |   |   | * |                  |   |
|                             |              |   |   | E |                  |   |
|                             |              |   |   | s |                  |   |
|                             |              |   |   | t |                  |   |
|                             |              |   |   | i |                  |   |
|                             |              |   |   | m |                  |   |
|                             |              |   |   | a |                  |   |
|                             |              |   |   | t |                  |   |
|                             |              |   |   | e |                  |   |
|                             |              |   |   | d |                  |   |
|                             |              |   |   | H |                  |   |
|                             |              |   |   | o |                  |   |
|                             |              |   |   | u |                  |   |
|                             |              |   |   | r |                  |   |
|                             |              |   |   | s |                  |   |
|                             |              |   |   | * |                  |   |
|                             |              |   |   | * |                  |   |
+-----------------------------+--------------+---+---+---+------------------+---+
| > **Type of Support         | > Masters    |   |   |   |                  |   |
| > Needed:**                 |              |   |   |   |                  |   |
+-----------------------------+--------------+---+---+---+------------------+---+
|                             | > Doctoral   |   |   |   |                  |   |
+-----------------------------+--------------+---+---+---+------------------+---+

  -----------------------------------------------------------------------
  Notes:

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+-----------------------+--------------------------------+---+----------+
| **Approval            |                                |   | **Date** |
| Signatures**          |                                |   |          |
+-----------------------+--------------------------------+---+----------+
| > Director of         |                                |   |          |
| > Biostatistics Core: |                                |   |          |
+-----------------------+--------------------------------+---+----------+
| > BRRC Deputy         |                                |   |          |
| > Director:           |                                |   |          |
+-----------------------+--------------------------------+---+----------+