Current Research Project Submission Form

Directions for completion of form:

The form below is available for you to make the details of your current research project available in the Cochrane Behavioral Medicine Database. The fields below are recommended, but please just fill in as many as you wish.

NOTE: By submitting this form you are providing permission to post this information in the Cochrane Behavioral Medicine Database. If you would like the information removed from the Cochrane Behavioral Medicine Database at any time, please email Louise Falzon

 
Contact Details
 
1. Name of investigator:
 
2. Institution/Affiliation:
 
3. Address:
 
4. Telephone number:
 
5. Email address:
 
Study Details
 
6. Name of study:
 
7. Study start date:
 
8. Expected completion date:
 
9. Trial registration number:
 
Study Characteristics
 
10. Study design
 
11. Health Condition Please write below. See list of available terms here.
 
12. Intervention Please write below. See list of available terms here.
 
13. Participants (Please tick the most appropriate)
All Infant: birth - 23 months
All Child: 0-18 years
All Adult: 19+ years
Newborn: birth - 1 month
Infant: 1- 23 months
Preschool Child: 2-5 years
Child: 6-12 years
Adolescent: 13-18 years
Adult: 19-44 years
Middle Aged: 45-64 years
Middle Aged + Aged: 45+ years
Aged: 65+ years
80 and over: 80+ years
 
14. Setting (Please tick as many as apply)
Community
Home
Outpatient (general outpatient settings e.g. family practice)
Inpatient
School
Specialty care (e.g. smoking cessation clinic, substance abuse program)
Workplace
 
15. Gender
Females only
Males only
 
16. Ethnicity:
African
African continental ancestry group
Asian continental ancestry group
Chinese
European continental ancestry group
Hispanic
Minority groups
North American Indian
 
17. Socioeconomic status
Low socioeconomic status
 
18. Provider (Profession of treatment dispenser; tick as many as apply)
Counselor
Dentist
Dietician
Health visitor
Multidisciplinary
Nurse
Occupational therapist
Occupational therapist
Outreach worker
Pharmacist
Physical therapist (Use for physiotherapist)
Physician
Psychiatrist
Psychologist
Social worker
Surgeon
Teacher
Therapist
Other: 
 
19. Abstract (Please provide an outline of the proposed study)
 
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