Below is a Proof-of-Concept Trial Preliminary Budget Cost form.  Item 2 is the total cost per patient, while items 3-11 reflect a breakdown of each associated cost.  If any of the associated costs are not known at this time, please leave the specific item blank, and indicate in the additional space below as to when an estimate will be available.  Please fill out all required (*) information in order that the form be reviewed by the Clinical Trials Group.  

Once the form has been completed, please use the "submit" button to send your information to our Clinical Trials Group.  Additional space has been provided on this form if you have any questions.

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1.  Study population*  males between ages and
females between ages and
mixture of males and females between ages and

2. Total cost (per patient)*

3. Initial status of subjects; physician examination*

4. Monthly physician examination*

5. Blood chemistries at beginning of trial*

6. Blood chemistries monthly*

7. Diet history at beginning of trial*

8. Diet review with dietitian, 30 minutes weekly*

9. Food supply management*

10. Record keeping coordination*

11. Other*

Please use the space below to detail any additional costs not covered here.  Additionally, you may use this space for any general or specific questions directed at the Clinical Trials Group

*Name