Subscribe to Our Newsletter

To subscribe to the Dissemination Core listserv
Click here.

You'll get weekly updates on funding opportunities and upcoming events via email. When you subscribe, please enter your name in addition to your email address.

Service and Information Request Form

To request Dissemination Core services or a consultation, please tell us about yourself and your project. A faculty or staff member from our team will contact you.
Note: fields marked with an asterisk (*) are required.

Contact Person's Information

Contact Person's First Name: *

Contact Person's Last Name: *

Contact Person's Email: *

Phone Number (office or work):

Cell Phone or Alternate Contact:

Principal Investigator Information (complete if different from contact person)

Principal Investigator's First Name:

Principal Investigator's Last Name:

Email:

Phone Number:

Institution or Department:

Is PI a member of Lineberger Comprehensive Cancer Center?:

Type of service needed (check all that apply, or you can describe service needs in the next item):

Assistance in developing your research proposal

Audience research

Assessing organizational readiness for change

Designing logic models

Identifying designs, tools and instruments

Measuring dissemination impact

Applying quality improvement techniques

Brokering partnerships

Setting up communication channels

Production support for adapting EBIs

Brief description of the project, idea or assistance needed:

Grant Information

Grant Funding Agency or Potential Funder:

Full Grant Title:

Funding Mechanism:

Are you a new or a returning user?:

For Dissemination Core use only

Faculty member providing services:

Number of consultation hours:

Date service provided (use the format: day/month/year, for example: 02/15/2009):

Form submitted by:

If brief follow-up is needed, describe below: