Clinical Trial and Research Study Request Form

Requestor Information

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Guilford Press Title Information

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How Guilford Material will be Used

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Number of Sites:

Number of Subjects:

TOTAL Administrations:

Duration of Study: from: to:

Method of Distribution: (Print, electronic, or other)

Anticipated Attendance / # Copies:

Number of Facilitators, Administrators, & Project Leads:

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Print only (quantity):

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Details for Electronic Administration:

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Supporting Documents

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