ACTRI BERD Services Request Form

ACTRI BERD Services Request Form
Biostatistic Support

Please contact the BERD team (actri-berd@health.ucsd.edu) for any questions prior to submitting your request. For more details on Biostatistic services, click here.
Service Type(s):
Please read and acknowledge the Biostatistics Service Level Agreement (SLA).
Pre-Award Support Services:

Other
Please select your grant type:

Other
Post-Award Support Services:

Other
Deadline type:
Please provide your external deadline (such as grant or abstract submission deadline):

MonthDayYear
Date
Have you previously corresponded with the BERD on this project and did they prompt you to submit this request?
6 Weeks are required to be able to complete the requested work. Please reach out to actri-berd@health.ucsd.edu if you would like some help planning next steps for your project. Alternatively, BERD team offers free walk in office hours durring the week. Click here if you would like more information.
- Study Information
- Study Title:
- Study Documents
  
  Please provide any documents that can help with this request
  Cancelof
- Please indicate ACTRI membership level:
- If you are not an ACTRI member yet, please click here to review membership eligibility criteria and submit your application. Once submitted, please select the applicable membership level from the above options to proceed.
- Contact Information
  
  Please specify the following information
- PI First Name:
- PI Last Name:
- PI Full Name
- PI Phone:
- PI Email:
  Please use @health.ucsd.edu email address if you have one!
- PI Title:
  
  Other
- PI Department:
- Contact Person same as PI?
- Contact Name:
  
  First NameLast Name
- Contact Name:
  First Name
- Last Name
- Contact Phone:
- Contact Email:
  Please use @health.ucsd.edu email address if you have one!
- Contact Title:
  
  Other
- Contact Department:
- Recharge Information
  
  Please provide valid fund manager and OFC chartstring information for recharge purposes.
  
  Click here to review current ACTRI recharge rates.
- Fund Manager Name:
  
  First NameLast Name
- Fund Manager Name:
  First Name
- Last Name
- Fund Manager Email:
  Please use @health.ucsd.edu email address if you have one!
- OFC Project:
  Always required! (7 digit numerical value)
- OFC Task:
  Always required! (1-3 digit numerical value)
- OFC Funding Source:
  Required for sponsored projects only! (5-7 character alphanumerical value)
- Award #:
- Providing incorrect or incomplete OFC chartstring information will require further clarification and delay the process! Contact your fund manager or use the chartstring verification tool (requires VPN connection) to ensure chartstring accuracy prior to submission.
- Additional Information
- Funding Agency:
- Institute/Funding Mechanisms (e.g. NIDDK RO1):
- Organizational Affiliation:
  
  Other
- Any further information or comments you would like to submit with this request:
- Current Date
  
  MonthDayYear
  Date
- Six Weeks From Today
  
  MonthDayYear
  Date
- ACTRI Service
- Service Type(s):
- Services Needed:
- Voucher Request (Yes/No)
- Method of Recharge (Text)
- Grant Type
- Harvest - PI LN, FN
- Contact Name
- Harvest - Contact LN, FN
- Fund Manager Name
- Harvest - Fund Manager LN, FN
- Should be Empty:

ACTRI BERD Services Request Form

Biostatistic Support

Study Information

Contact Information

Recharge Information