nutrition assessment shared resource (nasr) - fred hutch

Study Account Information Nutrition Assessment Shared Resource (NASR)

Study Account Information v2

To open a data processing and billing account for Food Frequency Questionnaires (FFQs), Dietary Recalls, Food Records, etc., please complete this form and return it by email to nasr@fredhutch.org.

STUDY INFORMATION

Study Title Study Acronym (if applicable)

Brief Description of Your Study Study Population

Age:

Sex:

Language:

Number of participants:

Funding Agency & Grant Number Start and end dates of the study:

CONTACT AND BILLING INFORMATION

Principal Investigator

Name:

Phone:

Email:

Institution:

Primary Contact Person (for data processing inquiries)

Name:

Phone:

Email:

Shipping Address:

Billing Contact Person (if different from primary)

Name:

Phone:

Email:

Billing Address:

Budget Number or P.O. Number (if applicable)

NUTRITION ASSESSMENT METHODS AND MATERIALS

Nutrition Assessment Method(s):

□ Direct data entry of 24-hour recalls (telephone)□ Food records (diaries)□ FFQ (Food Frequency Questionnaire)□ Other (specify):

Total estimated number of materials needed for study

FFQs:

Food Records:

Recalls:

Serving Size Booklets:

When this form has been received, your study will be entered into a tracking system. You will be assigned a unique 3-letter code. The code will be emailed to you. Please use it in all correspondence with NASR.

Please initial and date after you complete this form. Initial: Date:

EnglishSpanish

Other (specify):

__

City,

State Zip

City State Zip,