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Consultation Request Form for UCSF Researchers

Fields marked with an asterisk are required.

Important: all publications resulting from the utilization of CTSI resources are required to credit the CTSI grant by including the NIH Funding acknowledgement.

Information about you

The information we're requesting below helps us understand your needs better and captures who we are serving. Thank you in advance for completing and submitting this form.

MD PhD MCR/MPH/MS DDS RN PharmD    Other

Experience with Community-Engaged Research

  Yes    No

How did you hear about Community Engagement Program services?




Proposed Project Information

Types of Assistance Required *Check all that apply (at least one)

Getting Started
Developing a research question
Finding funding source
Reviewing research proposal
Finding potential community research partners
Establishing partnership infrastructure (roles, responsibilities)
Supporting existing partnerships
Assisting in study design
Reviewing IRB application
Addressing project sustainability
Establishing a community advisory board
Reviewing budget proposals for community components
Providing community-based participatory research mentorship
Training, please identify topic:
Other, please describe:
Data Collection
Identifying community samples
Reviewing survey instruments
Reviewing data collection methods
Reviewing consent procedures/instruments
Establishing an evaluation plan
Addressing recruitment, retention and logistical issues for research
Creating staff training, please identify topic:
Other, please describe:
Dissemination and Action Steps
Establishing authorship guidelines for community based participatory research
Engaging the community with research findings
Conducting alternative community-based dissemination
Writing for multiple audiences
Working with the media
Training providers
Implementing advocacy – local, state, national
Other, please describe:

Additional Comments