NORC Service Request Form

Nutrition Behavior Intervention (CHAI)

All fields are required
SELECT ONE OR MORE SERVICES DESIRED (to choose more than one service, hold down control-key while making multiple selections)
Additional Service Desired

Principal Investigator (PI)

If the PI is a NORC investigator, please select their name from the list provided. If the PI's name does not appear on the list, please select Not a Member and complete the PI information below.
For information on how to become a member of the NORC, please contact Michelle Collins at mcc@email.unc.edu.
PI Name
PI Email

Contact Person

Name of Contact Person (if PI is not the primary point of contact)
Contact Person's Phone Number
Contact E-mail Address
Are you a member of the Lineberger Cancer Center?

Grant Information

Please complete as much information as possible. If you do not have the information available, please enter N/A for non applicable.
Internal UNC Account Number (format x-xxxxx)
Grant funding agency or potential funder
Grant number assigned by funding agency (e.g. NIH P30DK056350)
Full Grant Title
Enter funding period for above grant
(Please enter current date if there is not a funding period associated with the grant)		 FROM cal     TO cal
Grant Funding Amount (annual direct) - this can be obtained from PI Other Support information or from your department administrator $ (enter a number without commas)
Nutrition Significance of Research (Project must contain a nutrition component in order to receive NORC services)
IRB protocol number (numbers only)
IRB approval date cal
IACUC protocol number
IACUC approval date cal

Please verify that all of the above information is complete and accurate, then click SUBMIT. Please contact Michelle Collins (mcc@email.unc.edu) should you have any problems completing the form.