Research Communications Intake Form

The Research Communications Intake Form, designed to collect key information and keep on file for future needs, is the first step for potential research communications support. Once you have completed the form, e-mail any supporting documents as an attachment to researchstoryideas@choa.org.

This form will be evaluated by our research leadership team to determine if the work meets criteria for communications support based on System priorities and likely media interest. If any additional information is needed or resources can be provided, a member of the Children’s Public Relations team will be in touch directly with next steps.

Name

First NameLast Name

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Titles (Children’s, Emory University and Georgia Tech, if applicable)

Clinical area or specialty

What is the name of the project, device, technology, drug or treatment that is being developed?

What stage of development is the project in?

In layman’s terms, what is this project aiming to solve?

How will children be impacted by this project? How many kids do we anticipate will be impacted?

Are there any bench-to-bedside patient stories that will help illustrate this project?

How is the project being funded?

Are there any conflicts of interests or existing relationships that we should be aware of?

Name all individuals or institions involved (e.g., Children’s, Emory University, Georgia Tech, etc.)

When is the anticipated commercialization date, if any?

Will this device, technology or drug require U.S. Food and Drug Administration (FDA) clearance or approval?

Who from the Pediatric Institute or Pediatric Technology Center operations team will be the liaison if additional information orcoordination is needed?

Name everyone who will need to review and approve this content