{"id":3412,"date":"2022-12-22T09:25:49","date_gmt":"2022-12-22T14:25:49","guid":{"rendered":"https:\/\/www.med.unc.edu\/medicine\/im\/research\/research-committee-and-project-application\/research-project-application\/"},"modified":"2022-12-22T09:42:58","modified_gmt":"2022-12-22T14:42:58","slug":"research-project-application","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/medicine\/im\/research\/research-committee-and-project-application\/research-project-application\/","title":{"rendered":"Research Project Application"},"content":{"rendered":"<p><em>This form is used to apply for permission to conduct research within our clinic.<\/em><\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/medicine\/im\/wp-json\/wp\/v2\/pages\/3412\/#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_35\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>X\/Twitter<\/label><div class='gfield_description' id='gfield_description_1_35'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_35' id='input_1_35' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Project Information<\/h3><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Name of Project<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Principal Investigator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Division Sponsor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_6'>(if you're a PI within the Division select yourself)<\/div><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select'  aria-describedby=\"gfield_description_1_6\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='ALEMAN' >ALEMAN<\/option><option value='BERKOWITZ' >BERKOWITZ<\/option><option value='CAREY' >CAREY<\/option><option value='CAVANAUGH' >CAVANAUGH<\/option><option value='CHELMINSKI' >CHELMINSKI<\/option><option value='CHUNG' >CHUNG<\/option><option value='COLFORD' >COLFORD<\/option><option value='CYKERT' >CYKERT<\/option><option value='DEWALT' >DEWALT<\/option><option value='DOLAN-SOTO' >DOLAN-SOTO<\/option><option value='EL AMRAOUI' >EL AMRAOUI<\/option><option value='FELTNER' >FELTNER<\/option><option value='GREIG' >GREIG<\/option><option value='IVES' >IVES<\/option><option value='JONAS' >JONAS<\/option><option value='KEYSERLING' >KEYSERLING<\/option><option value='KLIPSTEIN' >KLIPSTEIN<\/option><option value='MALONE' >MALONE<\/option><option value='MILLER' >MILLER<\/option><option value='PALMER' >PALMER<\/option><option value='RATNER' >RATNER<\/option><option value='REULAND' >REULAND<\/option><option value='SCOTT' >SCOTT<\/option><option value='SHAHEEN' >SHAHEEN<\/option><option value='SHILLIDAY' >SHILLIDAY<\/option><option value='SMITHSON' >SMITHSON<\/option><option value='WEIL' >WEIL<\/option><option value='WILEY CENE' >WILEY CENE<\/option><option value='OTHER' >OTHER<\/option><\/select><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>If &quot;Other,&quot; Who?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Research Question<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_1_8' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Brief Description of the purpose of the research<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_1_9' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Estimated Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_1_10_dmessage' name='input_10' id='input_1_10' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_10' class='gform_hidden' value='https:\/\/www.med.unc.edu\/medicine\/im\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Estimated End Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_11'>(use 1 year from start date if unsure)<\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_1_11_dmessage' name='input_11' id='input_1_11' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_11_date_format gfield_description_1_11\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_11_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_11' class='gform_hidden' value='https:\/\/www.med.unc.edu\/medicine\/im\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type of Project<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_12'>\n\t\t\t<div class='gchoice gchoice_1_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Rsearch'  id='choice_1_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_12_0' id='label_1_12_0' class='gform-field-label gform-field-label--type-inline'>Rsearch<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='CQI'  id='choice_1_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>CQI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_1_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Funded?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_13'>\n\t\t\t<div class='gchoice gchoice_1_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_1_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_1_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>If Yes, Type of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_1_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='NIH' >NIH<\/option><option value='AHRQ' >AHRQ<\/option><option value='Foundation' >Foundation<\/option><option value='UNC internal funding' >UNC internal funding<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>If No, what will data be used for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='CQI data' >CQI data<\/option><option value='Pilot data for future funding' >Pilot data for future funding<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Stage<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'     aria-invalid=\"false\" ><option value='NIH' >NIH<\/option><option value='Foundation' >Foundation<\/option><option value='Graduate Work' >Graduate Work<\/option><option value='CQI Study' >CQI Study<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_1_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Study Population<\/h3><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Age Range Start<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_19' id='input_1_19' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Age Range End<\/label><div class='ginput_container ginput_container_number'><input name='input_20' id='input_1_20' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Races<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_21'><div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='All Races'  id='choice_1_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>All Races<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Caucasian'  id='choice_1_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='African-American'  id='choice_1_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_3' id='label_1_21_3' class='gform-field-label gform-field-label--type-inline'>African-American<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Asian'  id='choice_1_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_4' id='label_1_21_4' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='American Indian'  id='choice_1_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_5' id='label_1_21_5' class='gform-field-label gform-field-label--type-inline'>American Indian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Other'  id='choice_1_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_6' id='label_1_21_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Male'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Female'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Both'  id='choice_1_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_2' id='label_1_22_2' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_1_23\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Number of Participants<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_1_23' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Disease State<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Anticoagulation'  id='choice_1_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>Anticoagulation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='COPD\/Asthma'  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2' class='gform-field-label gform-field-label--type-inline'>COPD\/Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Diabetes'  id='choice_1_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_3' id='label_1_24_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Heart Disease'  id='choice_1_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_4' id='label_1_24_4' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Heart Failure'  id='choice_1_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_5' id='label_1_24_5' class='gform-field-label gform-field-label--type-inline'>Heart Failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Hypertension'  id='choice_1_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_6' id='label_1_24_6' class='gform-field-label gform-field-label--type-inline'>Hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Oncology'  id='choice_1_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_7' id='label_1_24_7' class='gform-field-label gform-field-label--type-inline'>Oncology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Pain'  id='choice_1_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_8' id='label_1_24_8' class='gform-field-label gform-field-label--type-inline'>Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Psych'  id='choice_1_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_9' id='label_1_24_9' class='gform-field-label gform-field-label--type-inline'>Psych<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Renal Disease'  id='choice_1_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_11' id='label_1_24_11' class='gform-field-label gform-field-label--type-inline'>Renal Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Screening and Prevention'  id='choice_1_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_12' id='label_1_24_12' class='gform-field-label gform-field-label--type-inline'>Screening and Prevention<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Other'  id='choice_1_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_13' id='label_1_24_13' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_25' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_1_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Recruitment Information<\/h3><\/div><fieldset id=\"field_1_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Recruitment Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_27'><div class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Registry'  id='choice_1_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>Registry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='In Clinic'  id='choice_1_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_2' id='label_1_27_2' class='gform-field-label gform-field-label--type-inline'>In Clinic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Phone'  id='choice_1_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_3' id='label_1_27_3' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Other'  id='choice_1_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_4' id='label_1_27_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_1_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Recruitment Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_1_28' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you require an RA to be in the Clinic?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_29'>\n\t\t\t<div class='gchoice gchoice_1_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_1_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_1_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_1_30\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>If Yes, How Many 1\/2 Days per Week Will They Be There?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_1_30' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What Space Will They Need at Eastowne?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_31'><div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Not Applicable'  id='choice_1_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>Not Applicable<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Exam Room'  id='choice_1_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_2' id='label_1_31_2' class='gform-field-label gform-field-label--type-inline'>Exam Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_31_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.3' type='checkbox'  value='Cubicle\/Desk'  id='choice_1_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_3' id='label_1_31_3' class='gform-field-label gform-field-label--type-inline'>Cubicle\/Desk<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_31_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.4' type='checkbox'  value='Hallways'  id='choice_1_31_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_4' id='label_1_31_4' class='gform-field-label gform-field-label--type-inline'>Hallways<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_31_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.5' type='checkbox'  value='Waiting Room'  id='choice_1_31_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_5' id='label_1_31_5' class='gform-field-label gform-field-label--type-inline'>Waiting Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_31_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.6' type='checkbox'  value='Other'  id='choice_1_31_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_6' id='label_1_31_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_1_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Other<\/label><div class='gfield_description' id='gfield_description_1_32'>(any special considerations or special needs)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_1_32' class='textarea large'  aria-describedby=\"gfield_description_1_32\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Upload a copy of your IRB Application<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_33'>(scanned version of your approved IRB, stamped document is preferred)<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='102400000' \/><input name='input_33' id='input_1_33' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_33 gfield_description_1_33\" onchange='javascript:gformValidateFileSize( this, 102400000 );'  \/><span 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