Other Academic and Public Health 9/11-Related Research
To have a study included on New York City’s 9/11 health website (www.nyc.gov/9-11health) and/or in informational materials,
please complete the following application and email it to for approval.
Note: The researcher must have IRB approval and must respond “No” to questions 6 & 7.
Application Form
1. Title of study or project (200-character limit)2. Name of individual and organization submitting the request*
Principal Investigator:
Title:
Organization:
Mailing address:
City, State, Zip Code:
Telephone number:
Email address:
Funding source(s):
* This information will not be posted online.
3. Request for inclusion of study information (please check all that apply):On 9/11 health website
In 9/11 health literature
In WTC Health Registry literature
4. Please attach a short paragraph (maximum of 200 words) to describe your study and targeted recruitment subjects. In addition, please provide a telephone number and/or email address where recruitment subjects can contact you. Because this is the only text that will be published, you should also include the study’s title and the name of the organization submitting the request. If applicable, provide a website for your project.
5. Does the study have current Institutional Review Board approval? (As defined by the U.S. Department of Health and Human Services in the Code of Federal Regulations, Title 45, Part 46)
Yes:
No:
If Yes:
What is the name of the IRB?
What is the IRB’s Multiple Project Assurance (MPA) number or Federal-Wide Assurance (FWA) number?
6. Will any of the information obtained by the study be used as a basis for legal, administrative, or other actions, which may directly affect particular individuals or establishments as a result of their specific identification in this study?
Yes:
No:
7. Will any of the information obtained by the study be used as a basis for marketing purposes, including, but not limited to, the marketing of pharmaceutical drugs?
Yes:
No: