Request to use Dystonia International Patient Registry

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Request to use Dystonia International Patient Registry

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Date
Investigator
Institution
Street Address
City
State
Postal Code
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Phone Number
Alternate Phone Number
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Alternate E-mail Address
Project Title

To obtain access to the Registry any research proposal must provide the following documentation that will be reviewed by the DIPR Scientific Advisory Committee:

ü One-page summary of the study proposal including the title of the study, major objectives and hypothesis, specific aims, number of participants, inclusion and exclusion criteria, and experimental and analytical methods

IRB approval from the Investigator’s Institution
Informed consent, if applicable
NIH-style biosketch including the description of existing and/or anticipated financial support for the project

The DIPR Scientific Advisory Committee will review the proposal and, if approved, will contact the Investigator with further details.

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