Request for Research Space at InCHIP to Run Participants | Institute for Collaboration on Health, Intervention, and Policy (InCHIP)

The information below is required to request InCHIP research space. Please fill out the following form (which will take approximately 10 minutes). Once your request is reviewed by one of the InCHIP Directors, you will be contacted by an InCHIP administrative staff member.

InCHIP Information

Name(Required)

First Last

Email(Required)

Department/School at UConn(Required)

What is your position at UConn?(Required)

Faculty

Research Scientist

Research Associate/Assistant

Graduate Student

Undergraduate Student

Other

Please describe your position at UConn(Required)

Who is the Principal Investigator (PI) or faculty member supervising this project?(Required)

If you are the supervising PI or faculty member, please list your own name here.

Is the supervising PI or faculty member listed above part of the InCHIP Network?

Yes

Research Space Request

Project title and brief description of research(Required)

Is this project funded by an InCHIP internal or external grant?(Required)

Yes

What is the KFS number of the grant?

How is this research consistent with InCHIP's Mission Statement?

InCHIP Mission Statement: https://draft.chip.uconn.edu/mission/

Will individual interview rooms be needed?(Required)

Please include all date(s), day(s) of the week, and times requested for this project. For example, 9/6/21 - 12/15/21 on Wednesdays from 3-4 PM.(Required)

**Please note that if this request is not during InCHIP's business hours (Mon-Fri, 8am - 5pm), then InCHIP building cards (UConn ID card or InCHIP-issued proximity card) will be required for building entry. Specific instructions for utilizing the building outside of InCHIP's business hours will be included the email approving your request.**

How many participants will be run in the requested space during any given session?(Required)

If you are a graduate student, will your Faculty Advisor or Faculty Supervisor be in the building during the times listed above?(Required)

Yes

N/A

Do you have any IT support needs?(Required)

Yes

Please specify your IT needs below.(Required)

Phone

This field is for validation purposes and should be left unchanged.

Phone:	860.486.5917
E-mail:	860.486.4876
Address:	InCHIP Webmaster