Request for WECP lab and/or testing space / Research Participation Core

Date:
Name of Project:

Principal Investigator:

Contact Person:

Academic Department:

Contact Address:

Contact Phone:

Contact E-mail:

Grant Administered at (mark one):
Waisman Center
Other UW-Madison Specify:
Other – Specify:

Fund account to be billed:

University of Wisconsin Human Subjects Committee Protocol Number:

Approval Date:
Expiration Date:

First time request for WECP Research lab space – complete information in Part II.

Renewal of previously approved request – complete Section III.

SECTION II: FIRST TIME REQUEST

Source of research participants:
How many rooms would you like to reserve?
- Number of sound attenuated chambers:
- Number of interior windowless offices:
Preferred days and times per week you would like access to rooms.

Days of week and times of day: (check all that apply)

Sun

Mon

Tue

Wed

Thu

Fri

Sat

AM

PM

Please comment on why these particular days and times are preferred. What flexibility do you have to consider other days and times.

Length of time for each session/contact:
Estimated number of sessions in study:
Duration of testing period:

Starting date: (month/day/year)
Ending date: (month/day/year)

Room Utilization (click one)

		I will not leave testing materials in the room, therefore the room can be used by others when I am not scheduled to use it.

		I will leave testing materials in the room, but others may use the room if my materials are left in place.

		My investigation requires that I have exclusive access to the rooms during the entire testing period listed above.

SECTION III: RENEWAL REQUEST
Complete this section only if you wish to renew / extend a previously approved service

Will you continue to use the research room in the same manner and schedule as
your original request? Yes No

Duration of testing period:

Starting date (month/day/year)
Ending date (month/day/year)

If you answered No to the above question, please complete Section II above.

Contact RCP Staff at 263-5192 or rpc@waisman.wisc.edu if you have any questions.