Request to use WISC resources Use this online form to request access to the equipment and facilities of WISC "*" indicates required fields What is the name of the study?Official title (from IRB app)* Study Nickname* IRB protocol number* Who are the local study investigators?Principal InvestigatorPI Name* First Last PI Email* PI Phone*Study CoordinatorCoordinator Name First Last Coordinator Email Coordinator PhoneStudy PhysicianPhysician Name First Last Physician Email Physician PhoneHave you already discussed your study with WISC?Have you, at least to some extent, already discussed your project/request with someone in WISC management?*YesNoPlease indicate the WISC member(s) with whom you have already discussed your project/request Brady Riedner Stephanie Jones David Plante Giulio Tononi What happens in this study?Summary of research question:Data managementIs this a Data Only request?*YesNoHow will data transfer be executed?Briefly describe the type of data that you are requestingIs the data request covered by the IRB protocol indicated above?YesNoWho is sponsoring the study?Funding Source: Funding statusObtainedNotice of award pendingGrant in preparationOther (describe)Please describe other funding statusList the main inclusion/exclusion criteriaInclusion:Exclusion:Study duration and protocol overviewTotal expected study duration: Total expected number of subjects: Projected number of subjects/month: Briefly describe all relevant visits and tasks occurring at the Sleep Center:Who will be supervising and responsible for the participant(s) while they are at the Sleep Center? (Note: Research subjects cannot be left unattended) SchedulingPreferred/Requested days/nights of the week (provide justification if necessary) No preference Sunday Monday Tuesday Wednesday Thursday Friday Justification (optional):Time of StudyNighttime exclusivelyDaytime exclusivelyBoth day and nightProvide approximate start and end times for overnight visits: Provide approximate start and end times for daytime visits: Provide approximate start and end times for day/night visits: Nights to schedule Single night study Two nights (sequential) Other schedule (indicate below) Expected scheduling lead time > 1 month 2 - 4 weeks > 2 weeks (minimum) Describe other scheduleSetup and Special ServicesSetup requirements Full hdPSG [Net + full PSG] hdEEG + Safety [MSLT - Net, EMGchin, EKG, Oximeter] hdEEG Net Only Polysomnogram Only Special CircumstancesSelect all special services needed. After you have selected a services, please provide a justification for your selections below. Ad lib sleep in morning (no prescribed wake time) Specific bedtime / start time request Single technician staffing (1:1) Specific Room Give specific bedtime/start time and provide justificationProvide justification for single technician requestProvide details and justification for specific room requestIf you will require equipment for stimulation, please select the type of stimulation and describe Auditory Visual Other Briefly describe stimulationDay Studies Waking hd-EEG MSLT Other (please describe below) Describe otherPlease provide the details of your data only requestDo you need support from the following groups?Select the group(s) from which you will require support. After selection, describe the role of each group (e.g. which visits or tasks they will be performing). Clarify whether clinical staff will be performing these duties alone or whether they will be assisted by research staff Setup technicians Sleep technicians Nurses Reception (will research staff always be here to greet participant?) Physician: Sleep over read Physician: Medical (exclusion) consult Analysis Support Data Management / IT Support Role of Setup technicianRole of Sleep technicianRole of NursesRole of ReceptionRole of Physician (sleep over read)Role of Physician (medical consult)Role of Analysis SupportRole of Data Management / IT SupportCommentsThis field is for validation purposes and should be left unchanged.