Project ImpACT: Nomination of ImPACT Trials

Nomination of ImpACT Trials

Please complete the following form to submit your nomination of a trial as an ImpACT Trial.

Please provide as much information as possible to aid us in researching the trial. Items with
astericks(*) are required fields.

Please tell us the full name and/or the acronym for the trial:
Name of Trial*
Acronym for Trial
Is there a key reference that describes or is about the trial? For instance, the major outcomes paper from the trial or a review of the trial.
Key Reference (provide as much detail as possible: author, title, journal, year)
Type of Impact* (select all that apply)	Practice of medicine or public health Methods of designing, conducting or analyzing trials Course of subsequent research Understanding pathophysiology or biology Regulations, law or policy Ethical understanding and conduct of trials Other/Unknown
Please describe this impact as specifically as possible. We have provided some sample questions/issues you may wish to address in your description. You need not provide full comprehensive details here - we simply want enough information to help us determine how to proceed with this nomination (ie, what reviewers to send it to, what evidence we will need to seek, etc).
Description of Impact
Is there a person you would recommend talking to about this trial?
Suggested Contact
Contact Info for Suggested Contact
Why are you suggesting this person?
Suggested Contact Type
Please tell us a little about yourself so we can contact you about if we have any questions about your nomination.
Last Name*
First Name*
E-mail*
Phone
Date Submitted	11/21/2008