nutrition assessment shared resource (nasr) - fred hutch
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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 [email protected].
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,