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Contact Information
First name:	text field: single line 
Last name:	text field: single line 
Organization (i.e., C/I/O):	text field: single line 
Primary Phone: 	text field: single line 
Primary E-Mail: 	text field: single line 
Receive notifications? 		Checkbox 
Secondary Phone: 	text field: single line 
Secondary E-Mail: 	text field: single line 
Receive notifications? 		Checkbox 
Preferred contact method:	drop-down select

Who are the stakeholders (users/actors) that this proposed engagement will affect? Please list key technology users, data suppliers, report recipients, as well as any applicable governing guidelines (e.g., HIPAA).
Stakeholder*						Role**
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*Organization, C/I/O, user group, individual, etc.	**User, data supplier, report recipient, 									governing body.
Please note that you can choose more than one role per stakeholder.

Number of personnel participating in engagement:	text field: single line 

Project Summary
Project Title/Name: 	text field: single line 
Project Start Date: 	text field:auto calendar
Project End Date: 	text field:auto calendar
How long do you expect the project to take?
Duration	text field: single line 
We can best help you meet your goals if we have a general vision of your project. Please help us frame your project by addressing the following questions. Even if you are only requesting use of the physical laboratory space, a project summary will allow us to potentially leverage other R&D technology initiatives in working with you.
What is the motivation for this project? Indicate problems, challenges, and/or opportunities driving project interest. Also, feel free to indicate any technologies you have tried that have not worked well as well as those that you believe may have potential as a solution.
Project Summary:	text box: multi-line
What is your ultimate vision for this project? Ideally, what would you like to be able to do that you cannot do now, or cannot do in the way you want to do it? (optional)
Project Goals:	text box: multi-line
How will we know if the public health informatics R&D unit is successful regarding this project? What are some measures or metrics we can use to determine if we have achieved a viable solution (e.g., efficiency measures, usability guidelines, accessibility guidelines)?
Project Success Criteria:	text box: multi-line

Do you request a consultation meeting with our Research and Innovation Team?
Radial buttons: Yes  No
If yes...
When would you like to start using resources in the R&D Lab?	text field: single line 

Technology Requirements
What is/are the primary sources of data, if any, for the proposed technology? Project data sets must be examined (e.g., for privacy & security) prior to loading into the lab environment. The lab can provide synthetic data if necessary.
text box: multi-line
If this technology is to be used as part of a general work process, what are the basic high-level steps in the process? Five to six steps should cover most processes at a high level. (optional)
text box: multi-line
Is there anything about the nature of the project or key stakeholders not covered above that we should know about to facilitate success? Please feel free to provide any additional information.
text box: multi-line
Do you request developer resources from our Prototype Development Team?
Radial buttons: Yes  No

Do you request use of the Informatics R&D Laboratory?
(e.g,. would you like to have a web or database server prepared for you?)
Radial buttons: Yes  No
How many simultaneous physical workstations (lab seats) do you require at one time?
text field: single line 
If available, would you like to remotely access your R&D Laboratory resources?
Radial buttons: Yes  No
Please list names and email addresses for team members who require access to the lab:
Name				Email
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The Lab has defined a set of core technology standards which are installed as a default (i.e., not otherwise specified). Please modify as needed for your specific project requirements. Please list specific software needed in the Notes section.
Desktop/Client Requirements
#	Operating System*	Memory	Disk	VM?	Software**	Notes
Operating System: 	drop-down select
VM Type: 	drop-down select
Notes: 		text box: multi-line
Add More: 	button: will add another set of 3 fields like above
*Examples of Desktop OS platforms available: Windows XP, Windows 7 (32 bit / 64 bit), and Ubuntu Desktop Edition. Other platforms (Linux, Unix, Mac, Vista) may be possible based on availability and need.
**Examples of Desktop Software packages available: Visual Studio. Other software packages may be possible based on availability and need.

Server Requirements
#	Operating System*	Memory	Disk	VM?	Software**	Notes
Operating System: 	drop-down select
VM Type: 	drop-down select
Notes: 		text box: multi-line
Add More: 	button: will add another set of 3 fields like above
*Examples of Desktop OS platforms available: Windows XP, Windows 7 (32 bit / 64 bit), and Ubuntu Desktop Edition. Other platforms (Linux, Unix, Mac, Vista) may be possible based on availability and need.
**Examples of Desktop Software packages available: Visual Studio. Other software packages may be possible based on availability and need.

Will you need access to your prototype from outside the R&D Lab network?
Radial buttons: Yes  No
Do you expect custom network configurations to be required?
Radial buttons: Yes  No
Will your prototype connect to non-production systems/databases OUTSIDE the agency?
Radial buttons: Yes  No
Will your prototype connect to non-production systems/databases INSIDE the agency?
Radial buttons: Yes  No
Does your project require access to any third-party website and/or applications… [from paper form]
Website			Description
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Please feel free to provide any additional information regarding your technology needs below.
text box: multi-line
Please confirm that all the entered information is accurate. Click "Submit" when ready.
Once you have submitted your information, if you then need to make changes, please contact Dr. Savel at tsavel@cdc.gov.
Submit 		button

Internal fields/non-user facing

Approved project Start Date: 	text field:auto calendar
Approved project End Date: 	text field:auto calendar
Username	text field: single line
VM name	text field: single line
Group name	text field: single line
Proxy from	text field: single line 
Proxy to	text field: single line 
Desktop/Client Requirements		duplicate user facing fields?
Server Requirements			duplicate user facing fields?