Author’s Name:

Study Title:

Author’s Institution/Organization:

Study Location: (Specify Domestic, International, or Both; do not give details)

Planned Duration of Study:

STUDY DESCRIPTION (Expand this section of the form as needed. However, text written here should not exceed 10,000 characters).

Background:

Objectives:

Basic Study Design:

Investigator Contact Information:

Investigator Qualifications:

  Single- Center Trial                                 (Do NOT specify actual locations or co-investigators. 

  *Multi-Center Trial                                    Sites will be selected at a later date.)

*The STI CTG strongly encourages multi-site proposals, although it does recognize that smaller studies may be more appropriately conducted at a single site.

ESTIMATED COSTS                         Budgets for approved Concepts are considered binding.
In House:
Field:
Total Budget:

Submitted budgets should state the total dollar figure for the anticipated life of the study (including monies for the total number of anticipated sites). Please note that Concepts with budgets of > $ 2million dollars must be approved by an EC member before submission to the network.

FUNDING SOURCE(S) EXTERNAL TO THE STI CTG (if any):