{"id":850,"date":"2025-04-23T16:40:33","date_gmt":"2025-04-23T15:40:33","guid":{"rendered":"https:\/\/helsinn.com\/?page_id=850"},"modified":"2025-08-07T09:43:45","modified_gmt":"2025-08-07T08:43:45","slug":"grant-request-form","status":"publish","type":"page","link":"https:\/\/helsinn.com\/en_us\/technology\/research-grants\/grant-request-form\/","title":{"rendered":"Grant Request Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"850\" class=\"elementor elementor-850\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1c80b263 e-flex e-con-boxed e-con e-parent\" data-id=\"1c80b263\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-18b68638 e-con-full e-flex e-con e-child\" data-id=\"18b68638\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1261c72b top-title in-pages elementor-widget elementor-widget-heading\" data-id=\"1261c72b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Technology<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-36d5bc42 e-con-full e-flex e-con e-child\" data-id=\"36d5bc42\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7b2695a2 elementor-widget__width-initial elementor-widget-mobile__width-inherit elementor-widget elementor-widget-heading\" data-id=\"7b2695a2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Grant Request Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-401f55fa e-flex e-con-boxed e-con e-parent\" data-id=\"401f55fa\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-6520d114 e-con-full e-flex e-con e-child\" data-id=\"6520d114\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b35ca0d elementor-widget elementor-widget-text-editor\" data-id=\"b35ca0d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div>We believe in the importance of supporting research studies that advance medical and scientific knowledge about our products. All researchers interested in conducting their own study can directly submit a study proposal through the dedicated portal; this will require completing the Helsinn Research Grant Submission Online Form. The proposal will be carefully evaluated, and the outcome will be communicated as a follow-up to the submitted Research Grant request.<\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4ad5a34 e-flex e-con-boxed e-con e-parent\" data-id=\"4ad5a34\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0ddd4b9 elementor-widget elementor-widget-heading\" data-id=\"0ddd4b9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Please submit your Grant Request:\n<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d8c299d elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"d8c299d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;button_width&quot;:&quot;100&quot;}\" data-no-translation=\"\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style>.elementor-element-d8c299d{display:none !important}<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-23249c3 elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"23249c3\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;button_width&quot;:&quot;100&quot;}\" data-no-translation=\"\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<template id=\"cfef_logic_data_23249c3\" class=\"cfef_logic_data_js\" data-form-id=\"23249c3\">{&quot;field_c66f730&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_3db2e57&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;United 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class=\"elementor-form\" method=\"post\" name=\"NEW_Grant Request Form - USA\" aria-label=\"NEW_Grant Request Form - USA\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"850\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"23249c3\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_f33b0a2 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"SECTION 1 \u2013 CONTACT GENERAL INFORMATION\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1006d83 elementor-col-100\">\n\t\t\t\t\t<h3>SECTION 1 \u2013 CONTACT GENERAL INFORMATION<\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2ffd167 elementor-col-100\">\n\t\t\t\t\t<h5>INVESTIGATOR INFORMATION:<\/h5>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b2eec4c elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b2eec4c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b2eec4c]\" id=\"form-field-field_b2eec4c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cbae4d7 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cbae4d7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTitle\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cbae4d7]\" id=\"form-field-field_cbae4d7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4ed1846 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4ed1846\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInstitution\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4ed1846]\" id=\"form-field-field_4ed1846\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3db2e57 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3db2e57\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCountry\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3db2e57]\" id=\"form-field-field_3db2e57\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Afghanistan\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Albania\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Algeria\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Andorra\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Angola\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Argentina\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Armenia\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Australia\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Austria\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\">Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Barbados\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belarus\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belgium\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belize\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Benin\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bolivia\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Botswana\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brazil\">Brazil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brunei\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bulgaria\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burkina Faso\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burundi\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cabo Verde\">Cabo Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cambodia\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cameroon\">Cameroon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Canada\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Central African Republic\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chad\">Chad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chile\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"China\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colombia\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Comoros\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Congo\">Congo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Democratic Republic of the Congo\">Democratic Republic of the Congo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Costa Rica\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\u00f4te d\u2019Ivoire\">C\u00f4te d\u2019Ivoire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Croatia\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cuba\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cyprus\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Czechia\">Czechia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Denmark\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Djibouti\">Djibouti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dominica\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dominican Republic\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Egypt\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Estonia\">Estonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eswatini\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Fiji\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Finland\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"France\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gabon\">Gabon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gambia\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Germany\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ghana\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Greece\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grenada\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guyana\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Haiti\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Holy See (Vatican City)\">Holy See (Vatican City)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Honduras\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hungary\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iceland\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"India\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iran\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iraq\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ireland\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Israel\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Italy\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jamaica\">Jamaica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Japan\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jordan\">Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kazakhstan\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kenya\">Kenya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kiribati\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Korea\">North Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Korea\">South Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kuwait\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kyrgyzstan\">Kyrgyzstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Laos\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Latvia\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lebanon\">Lebanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lesotho\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liberia\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Libya\">Libya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malawi\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maldives\">Maldives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mali\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malta\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\">Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mexico\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Micronesia\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moldova\">Moldova<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Monaco\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mongolia\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montenegro\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Morocco\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mozambique\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Myanmar\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Namibia\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nauru\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nepal\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Netherlands\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Zealand\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nicaragua\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Niger\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nigeria\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Macedonia\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Norway\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oman\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pakistan\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palau\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palestine\">Palestine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Panama\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Papua New Guinea\">Papua New Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Paraguay\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Peru\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Philippines\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Poland\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Portugal\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Qatar\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Romania\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Russia\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Samoa\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"San Marino\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"S\u00e3o Tom\u00e9 and Pr\u00edncipe\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Senegal\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Serbia\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\">Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Singapore\">Singapore<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\">Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Somalia\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Africa\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Sudan\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spain\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sudan\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Suriname\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sweden\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Syria\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tanzania\">Tanzania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Thailand\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Timor-Leste\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Togo\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tonga\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\">Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkey\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uganda\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Kingdom\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United States\">United States<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\">Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Venezuela\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vietnam\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yemen\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zambia\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\">Zimbabwe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c66f730 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c66f730\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c66f730]\" id=\"form-field-field_c66f730\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AL\">Alabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AK\">Alaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AZ\">Arizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AR\">Arkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CA\">California<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CO\">Colorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CT\">Connecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DE\">Delaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"FL\">Florida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GA\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"HI\">Hawaii<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ID\">Idaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IL\">Illinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IN\">Indiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"IA\">Iowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KS\">Kansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"KY\">Kentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LA\">Louisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ME\">Maine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">Maryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MA\">Massachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MI\">Michigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MN\">Minnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MS\">Mississippi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MO\">Missouri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MT\">Montana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NE\">Nebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NV\">Nevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NH\">New Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NJ\">New Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NM\">New Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NY\">New York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"NC\">North Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"ND\">North Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OH\">Ohio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OK\">Oklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OR\">Oregon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PA\">Pennsylvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RI\">Rhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SC\">South Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"SD\">South Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TN\">Tennessee<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TX\">Texas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UT\">Utah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VT\">Vermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VA\">Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WA\">Washington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WV\">West Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WI\">Wisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"WY\">Wyoming<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DC\">District of Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PR\">Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"GU\">Guam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AS\">American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"VI\">U.S. Virgin Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MP\">Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7ef5b25 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7ef5b25\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7ef5b25]\" id=\"form-field-field_7ef5b25\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bf80f39 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bf80f39\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bf80f39]\" id=\"form-field-field_bf80f39\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7c4a7bf elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7c4a7bf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostal code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7c4a7bf]\" id=\"form-field-field_7c4a7bf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_08b6149 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_08b6149\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNPI Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_08b6149]\" id=\"form-field-field_08b6149\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_782436a elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_782436a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_782436a]\" id=\"form-field-field_782436a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_14b8909 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_14b8909\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProfessional email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_14b8909]\" id=\"form-field-field_14b8909\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_1f0422e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1f0422e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSub-investigator(s)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_1f0422e]\" id=\"form-field-field_1f0422e\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_685818d elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"SECTION 2 \u2013 STUDY DETAILS\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_424b70d elementor-col-100\">\n\t\t\t\t\t<h3>SECTION 2 \u2013 STUDY DETAILS<\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_39bad2a elementor-col-100\">\n\t\t\t\t\t<h5>STUDY TITLE AND RATIONALE<\/h5>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ed64792 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ed64792\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Title\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ed64792]\" id=\"form-field-field_ed64792\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bf101ed elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bf101ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTherapeutic Area\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_bf101ed]\" id=\"form-field-field_bf101ed\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select your Therapeutic Area<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cancer Supportive Care\">Cancer Supportive Care<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oncology\">Oncology<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f22e4f4 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f22e4f4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf \"Other\" please specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f22e4f4]\" id=\"form-field-field_f22e4f4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6926f6f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6926f6f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhase\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Preclinical\" id=\"form-field-field_6926f6f-0\" name=\"form_fields[field_6926f6f]\" required=\"required\"> <label for=\"form-field-field_6926f6f-0\">Preclinical<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Clinical\" id=\"form-field-field_6926f6f-1\" name=\"form_fields[field_6926f6f]\" required=\"required\"> <label for=\"form-field-field_6926f6f-1\">Clinical<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4725d19 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4725d19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHelsinn product\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4725d19]\" id=\"form-field-field_4725d19\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Akynzeo\u00ae\">Akynzeo\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aloxi\u00ae Onicit\u00ae Paloxi\u00ae\">Aloxi\u00ae Onicit\u00ae Paloxi\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arokaris\u00ae\">Arokaris\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Adlumiz\u00ae\">Adlumiz\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Valchlor\u00ae\/Ledaga\u00ae\">Valchlor\u00ae\/Ledaga\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aulin\u00ae Mesulid\u00ae Nisulid\u00ae\">Aulin\u00ae Mesulid\u00ae Nisulid\u00ae<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_fb89c7a elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fb89c7a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy rationale and background\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_fb89c7a]\" id=\"form-field-field_fb89c7a\" rows=\"5\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d7832a1 elementor-col-100\">\n\t\t\t\t\t<h5>STUDY DESIGN<\/h5>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_31cd862 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_31cd862\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Type \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_31cd862]\" id=\"form-field-field_31cd862\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Interventional\">Interventional<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Non-Interventional \/ Observational \/ Real World\">Non-Interventional \/ Observational \/ Real World<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Retrospective Data Review\">Retrospective Data Review<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7d2fc13 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7d2fc13\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Type (Non-Interventional \/ Observational \/ Real World)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7d2fc13]\" id=\"form-field-field_7d2fc13\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Epidemiology\">Epidemiology<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Outcomes Research\">Outcomes Research<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Registry (retrospective\/prospective)\">Registry (retrospective\/prospective)<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_345030f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_345030f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease, specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_345030f]\" id=\"form-field-field_345030f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_83a8c19 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_83a8c19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Design <small>(check all that apply) <\/small>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Phase I\/II\" id=\"form-field-field_83a8c19-0\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-0\">Phase I\/II<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Phase III\t\" id=\"form-field-field_83a8c19-1\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-1\">Phase III\t<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Phase IV\" id=\"form-field-field_83a8c19-2\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-2\">Phase IV<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Single-Blind\t\" id=\"form-field-field_83a8c19-3\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-3\">Single-Blind\t<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Double-Blind\" id=\"form-field-field_83a8c19-4\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-4\">Double-Blind<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Open Label\" id=\"form-field-field_83a8c19-5\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-5\">Open Label<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Placebo Control\" id=\"form-field-field_83a8c19-6\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-6\">Placebo Control<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Active Control\" id=\"form-field-field_83a8c19-7\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-7\">Active Control<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Historic Control\" id=\"form-field-field_83a8c19-8\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-8\">Historic Control<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Single Arm\" id=\"form-field-field_83a8c19-9\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-9\">Single Arm<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dose Comparison \" id=\"form-field-field_83a8c19-10\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-10\">Dose Comparison <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Parallel\" id=\"form-field-field_83a8c19-11\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-11\">Parallel<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cross-Over\" id=\"form-field-field_83a8c19-12\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-12\">Cross-Over<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_83a8c19-13\" name=\"form_fields[field_83a8c19][]\"> <label for=\"form-field-field_83a8c19-13\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4a36d9f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4a36d9f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease, specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4a36d9f]\" id=\"form-field-field_4a36d9f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ae4cacc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ae4cacc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Objectives <small>(check all that apply) <\/small>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Efficacy (measurement of the capacity of beneficial change)\" id=\"form-field-field_ae4cacc-0\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-0\">Efficacy (measurement of the capacity of beneficial change)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Effectiveness (how well a treatment works in practice)\" id=\"form-field-field_ae4cacc-1\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-1\">Effectiveness (how well a treatment works in practice)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pharmacokinetics\" id=\"form-field-field_ae4cacc-2\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-2\">Pharmacokinetics<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Safety\" id=\"form-field-field_ae4cacc-3\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-3\">Safety<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Outcomes Research\" id=\"form-field-field_ae4cacc-4\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-4\">Outcomes Research<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pharmacogenomics\" id=\"form-field-field_ae4cacc-5\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-5\">Pharmacogenomics<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Quality of Life\" id=\"form-field-field_ae4cacc-6\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-6\">Quality of Life<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_ae4cacc-7\" name=\"form_fields[field_ae4cacc][]\"> <label for=\"form-field-field_ae4cacc-7\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_730df92 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_730df92\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease, specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_730df92]\" id=\"form-field-field_730df92\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_7b857d4 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b857d4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Primary Objective\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_7b857d4]\" id=\"form-field-field_7b857d4\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f61859f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f61859f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Endpoint(s)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f61859f]\" id=\"form-field-field_f61859f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_aa7ca64 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aa7ca64\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSecondary Endpoint(s)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_aa7ca64]\" id=\"form-field-field_aa7ca64\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a9c2409 elementor-col-100\">\n\t\t\t\t\t<h5>Treatment Groups <\/h5>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4b77f22 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b77f22\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Arm 1:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4b77f22]\" id=\"form-field-field_4b77f22\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1904bff elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1904bff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Arm 2 (etc., if any):\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1904bff]\" id=\"form-field-field_1904bff\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9dade85 elementor-col-100\">\n\t\t\t\t\t<h5>STUDY POPULATION AND STUDY DURATION <\/h5>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_94296c2 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_94296c2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy population\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_94296c2]\" id=\"form-field-field_94296c2\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_45653c9 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_45653c9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSample size <small>(if applicable, include sample size calculation)<\/small>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_45653c9]\" id=\"form-field-field_45653c9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_12ce198 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12ce198\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNumber of centers\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_12ce198]\" id=\"form-field-field_12ce198\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"0\" max=\"10000\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_90b7238 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_90b7238\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy duration <small>(Number of cycles, observation period, total duration, estimated study start date)<\/small>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_90b7238]\" id=\"form-field-field_90b7238\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_636357c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_636357c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tKey inclusion \/ Exclusion criteria\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_636357c]\" id=\"form-field-field_636357c\" rows=\"4\" placeholder=\"Specify here: \"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_43f6896 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_43f6896\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlans for Publication\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_43f6896-0\" name=\"form_fields[field_43f6896]\"> <label for=\"form-field-field_43f6896-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_43f6896-1\" name=\"form_fields[field_43f6896]\"> <label for=\"form-field-field_43f6896-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c15209c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c15209c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf Yes, briefly explain here: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_c15209c]\" id=\"form-field-field_c15209c\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6b836ce elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"SECTION 3 \u2013 HELSINN SUPPORT AND BUDGET\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_3306736 elementor-col-100\">\n\t\t\t\t\t<h3>SECTION 3 \u2013 HELSINN SUPPORT AND BUDGET<\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0a9c59f elementor-col-100\">\n\t\t\t\t\t<h5>TYPE OF SUPPORT REQUESTED<\/h5>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4f9a02e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4f9a02e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tType of Study Support <small>(Check all that apply)<\/small>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Drug\" id=\"form-field-field_4f9a02e-0\" name=\"form_fields[field_4f9a02e][]\"> <label for=\"form-field-field_4f9a02e-0\">Drug<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Financial\" id=\"form-field-field_4f9a02e-1\" name=\"form_fields[field_4f9a02e][]\"> <label for=\"form-field-field_4f9a02e-1\">Financial<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_4f9a02e-2\" name=\"form_fields[field_4f9a02e][]\"> <label for=\"form-field-field_4f9a02e-2\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6749b44 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6749b44\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease, specify:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6749b44]\" id=\"form-field-field_6749b44\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_af141b0 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_af141b0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSpecify drug(s) and formulation being requested\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_af141b0]\" id=\"form-field-field_af141b0\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_16d76fb elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_16d76fb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBudget currency\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"USD\" id=\"form-field-field_16d76fb-0\" name=\"form_fields[field_16d76fb]\" required=\"required\"> <label for=\"form-field-field_16d76fb-0\">USD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"EUR\" id=\"form-field-field_16d76fb-1\" name=\"form_fields[field_16d76fb]\" required=\"required\"> <label for=\"form-field-field_16d76fb-1\">EUR<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"CHF\" id=\"form-field-field_16d76fb-2\" name=\"form_fields[field_16d76fb]\" required=\"required\"> <label for=\"form-field-field_16d76fb-2\">CHF<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-field_16d76fb-3\" name=\"form_fields[field_16d76fb]\" required=\"required\"> <label for=\"form-field-field_16d76fb-3\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2c2d8d2 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c2d8d2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease, specify:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2c2d8d2]\" id=\"form-field-field_2c2d8d2\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a76c9c8 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a76c9c8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTotal value\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a76c9c8]\" id=\"form-field-field_a76c9c8\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"en_us\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-327fb09 elementor-button-align-start elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-form\" data-id=\"327fb09\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;button_width&quot;:&quot;100&quot;}\" data-no-translation=\"\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style>.elementor-element-327fb09{display:none !important}<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e4f6f25 elementor-button-align-start elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-form\" data-id=\"e4f6f25\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;button_width&quot;:&quot;100&quot;}\" data-no-translation=\"\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<template id=\"cfef_logic_data_e4f6f25\" class=\"cfef_logic_data_js\" data-form-id=\"e4f6f25\">{&quot;field_576e164&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_c5d4a5f&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Rest-of-the-world&quot;,&quot;_id&quot;:&quot;fb86114&quot;}]},&quot;other_title&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_36a2c4f&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;87e6ed2&quot;}]},&quot;field_7e425d8&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_9efc1b2&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;b723668&quot;}]},&quot;field_d9e0e01&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_1989383&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;f9b2678&quot;}]},&quot;field_46d8bbd&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_7509ccc&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;0aea146&quot;}]}}<\/template>\t\t<form class=\"elementor-form\" method=\"post\" name=\"Grant Request Form - USA\" aria-label=\"Grant Request Form - USA\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"850\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"e4f6f25\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_0990997 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Applicant Details\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f1b7617 elementor-col-100\">\n\t\t\t\t\tApplicant Contact Details\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-last_name elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-last_name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[last_name]\" id=\"form-field-last_name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c5d4a5f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c5d4a5f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhere is this application being submitted from:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"United-States\" id=\"form-field-field_c5d4a5f-0\" name=\"form_fields[field_c5d4a5f]\" required=\"required\"> <label for=\"form-field-field_c5d4a5f-0\">United States<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Rest-of-the-world\" id=\"form-field-field_c5d4a5f-1\" name=\"form_fields[field_c5d4a5f]\" required=\"required\"> <label for=\"form-field-field_c5d4a5f-1\">Rest of the world<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_576e164 elementor-col-100\">\n\t\t\t\t\t<h6 style=\"background: #FABCA2; color: black; width: fit-content; padding: 10px; 20px; border-radius: 50px; font-size: 14px; font-weight: 400;\">You\u2019re on the U.S. site. <b>Non-U.S.<\/b> requests are routed to the Global site. Switch region top-right, or continue here.<\/h6>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d7e4b8a elementor-col-100\">\n\t\t\t\t\tContact Email Address\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEnter Email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_93d8576 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_93d8576\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tConfirm Email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_93d8576]\" id=\"form-field-field_93d8576\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_50496eb elementor-col-100\">\n\t\t\t\t\tApplicant Phone Number\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_457c6dc elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_457c6dc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease provide full telephone number including international dialling code e.g. +41 ## ### ## ##\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_457c6dc]\" id=\"form-field-field_457c6dc\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_801fb52 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"2. Primary Investigator Details\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d1ef096 elementor-col-100\">\n\t\t\t\t\t<h5 style=\"color: black\">Primary investigator details<\/h5><hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_36a2c4f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_36a2c4f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChoose title\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_36a2c4f]\" id=\"form-field-field_36a2c4f\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select your title<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MD\">MD<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PhD\">PhD<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MDPhD\">MD PhD<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DO\">DO<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"PharmD\">PharmD<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DDS\">DDS<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DVM\">DVM<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"MSc\">MSc<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"DSc\">DSc<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"RN\">RN<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-other_title elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-other_title\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSpecify other title\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[other_title]\" id=\"form-field-other_title\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cd10f05 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cd10f05\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cd10f05]\" id=\"form-field-field_cd10f05\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7162bd1 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7162bd1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7162bd1]\" id=\"form-field-field_7162bd1\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4e3967e elementor-col-100\">\n\t\t\t\t\tPrimary investigator Email\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_64413ab elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_64413ab\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEnter Email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_64413ab]\" id=\"form-field-field_64413ab\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_f4e5b9b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f4e5b9b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tConfirm Email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_f4e5b9b]\" id=\"form-field-field_f4e5b9b\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2e28b1e elementor-col-100\">\n\t\t\t\t\tPrimary investigator Phone\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_2ae76b7 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2ae76b7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease provide full telephone number including international dialling code e.g. +41 ## ### ## ##\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_2ae76b7]\" id=\"form-field-field_2ae76b7\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_abc2e3d elementor-col-100\">\n\t\t\t\t\t<h5 style=\"color: black\">Institution Details<\/h5><hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_695c1cd elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_695c1cd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInstitution Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_695c1cd]\" id=\"form-field-field_695c1cd\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d5eebeb elementor-col-100\">\n\t\t\t\t\tInstitution Address\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_82a7f28 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_82a7f28\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStreet address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_82a7f28]\" id=\"form-field-field_82a7f28\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_509f48f elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_509f48f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_509f48f]\" id=\"form-field-field_509f48f\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7645c54 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7645c54\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCounty \/ State \/ Region\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7645c54]\" id=\"form-field-field_7645c54\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e850cf9 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e850cf9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZIP \/ Post Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e850cf9]\" id=\"form-field-field_e850cf9\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8c9ae22 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8c9ae22\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCountry\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8c9ae22]\" id=\"form-field-field_8c9ae22\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Choose Country<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Afghanistan\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Albania\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Algeria\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Andorra\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Angola\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Argentina\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Armenia\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Australia\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Austria\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\">Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Barbados\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belarus\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belgium\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belize\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Benin\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bolivia\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Botswana\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brazil\">Brazil<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brunei\">Brunei<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bulgaria\">Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burkina Faso\">Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burundi\">Burundi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cabo Verde\">Cabo Verde<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cambodia\">Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cameroon\">Cameroon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Canada\">Canada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Central African Republic\">Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chad\">Chad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chile\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"China\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colombia\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Comoros\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Congo, Democratic Republic of the\">Congo, Democratic Republic of the<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Congo, Republic of the\">Congo, Republic of the<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Costa Rica\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Croatia\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cuba\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cyprus\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Czechia\">Czechia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Denmark\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Djibouti\">Djibouti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dominica\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dominican Republic\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Egypt\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Estonia\">Estonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eswatini\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Fiji\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Finland\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"France\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gabon\">Gabon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gambia\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Germany\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ghana\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Greece\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grenada\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guyana\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Haiti\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Honduras\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hungary\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iceland\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"India\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iran\">Iran<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iraq\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ireland\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Israel\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Italy\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jamaica\">Jamaica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Japan\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jordan\">Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kazakhstan\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kenya\">Kenya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kiribati\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Korea, North\">Korea, North<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Korea, South\">Korea, South<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kosovo\">Kosovo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kuwait\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kyrgyzstan\">Kyrgyzstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Laos\">Laos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Latvia\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lebanon\">Lebanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lesotho\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liberia\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Libya\">Libya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malawi\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maldives\">Maldives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mali\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malta\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\">Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mexico\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Micronesia\">Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moldova\">Moldova<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Monaco\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mongolia\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montenegro\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Morocco\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mozambique\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Myanmar\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Namibia\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nauru\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nepal\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Netherlands\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Zealand\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nicaragua\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Niger\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nigeria\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Macedonia\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Norway\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oman\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pakistan\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palau\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palestine\">Palestine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Panama\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Papua New Guinea\">Papua New Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Paraguay\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Peru\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Philippines\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Poland\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Portugal\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Qatar\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Romania\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Russia\">Russia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Samoa\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"San Marino\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Senegal\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Serbia\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\">Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Singapore\">Singapore<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\">Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Somalia\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Africa\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Sudan\">South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spain\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sudan\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Suriname\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sweden\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Syria\">Syria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taiwan\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tanzania\">Tanzania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Thailand\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Timor-Leste\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Togo\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tonga\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\">Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkey\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uganda\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Kingdom\">United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United States\">United States<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\">Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vatican City\">Vatican City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Venezuela\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vietnam\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yemen\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zambia\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\">Zimbabwe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_da228f7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_da228f7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState Licence Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_da228f7]\" id=\"form-field-field_da228f7\" class=\"elementor-field elementor-size-md  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e8b49de elementor-col-100\">\n\t\t\t\t\t<h5 style=\"color: black\">Subinvestigator(s)<\/h5><hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_4bee659 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4bee659\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name(s) and Last Name(s)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_4bee659]\" id=\"form-field-field_4bee659\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_9ccf935 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"3. Study Details and Rationale\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2b40151 elementor-col-100\">\n\t\t\t\t\t<h5 style=\"color: black\">Study Details and Rationale<\/h5><hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_266da08 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_266da08\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Title\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_266da08]\" id=\"form-field-field_266da08\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9efc1b2 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9efc1b2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTherapeutic Area\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Cancer Supportive Care\" id=\"form-field-field_9efc1b2-0\" name=\"form_fields[field_9efc1b2]\" required=\"required\"> <label for=\"form-field-field_9efc1b2-0\">Cancer Supportive Care<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Oncology\" id=\"form-field-field_9efc1b2-1\" name=\"form_fields[field_9efc1b2]\" required=\"required\"> <label for=\"form-field-field_9efc1b2-1\">Oncology<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Hemato-Oncology\" id=\"form-field-field_9efc1b2-2\" name=\"form_fields[field_9efc1b2]\" required=\"required\"> <label for=\"form-field-field_9efc1b2-2\">Hemato-Oncology<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-field_9efc1b2-3\" name=\"form_fields[field_9efc1b2]\" required=\"required\"> <label for=\"form-field-field_9efc1b2-3\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7e425d8 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7e425d8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf other, please specify\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7e425d8]\" id=\"form-field-field_7e425d8\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_2a15559 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2a15559\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClinical or Pre-Clinical\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Pre-clinical\" id=\"form-field-field_2a15559-0\" name=\"form_fields[field_2a15559]\" required=\"required\"> <label for=\"form-field-field_2a15559-0\">Pre-clinical<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Clinical\" id=\"form-field-field_2a15559-1\" name=\"form_fields[field_2a15559]\" required=\"required\"> <label for=\"form-field-field_2a15559-1\">Clinical<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b6c4dfc elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b6c4dfc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHelsinn Product\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b6c4dfc]\" id=\"form-field-field_b6c4dfc\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AKYNZEO\u00ae\">AKYNZEO\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aloxi\u00ae Onicit\u00ae Paloxi\u00ae\">Aloxi\u00ae Onicit\u00ae Paloxi\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arokaris\u00ae\">Arokaris\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Adlumiz\u00ae\">Adlumiz\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Valchlor\u00ae\/Ledaga\u00ae\">Valchlor\u00ae\/Ledaga\u00ae<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aulin\u00ae Mesulid\u00ae Nisulid\u00ae\">Aulin\u00ae Mesulid\u00ae Nisulid\u00ae<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_8fdf042 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8fdf042\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Rationale and Background\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_8fdf042]\" id=\"form-field-field_8fdf042\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_9fd0494 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9fd0494\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStudy Objectives <span style=\"color: red;\">*<\/span> <br><br><span><strong>Examples:<\/strong> <li>To demonstrate the non-inferiority in terms of efficacy of Drug A compared to Drug B<\/li>   <li>To demonstrate the superiority in terms of efficacy of Drug A compared to Drug B<\/li>   <li>To evaluate the Quality of Life in patients receiving Drug A compared to Standard of Care<\/li>   <li>To describe the safety profile of Drug A<\/li><br>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_9fd0494]\" id=\"form-field-field_9fd0494\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_8d92a2a elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"4. Support and Budget\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6067857 elementor-col-100\">\n\t\t\t\t\t<h5 style=\"color: black\">Support and Budget<\/h5><hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1989383 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1989383\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSupport request\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Drug\" id=\"form-field-field_1989383-0\" name=\"form_fields[field_1989383]\" required=\"required\"> <label for=\"form-field-field_1989383-0\">Drug<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Financial\" id=\"form-field-field_1989383-1\" name=\"form_fields[field_1989383]\" required=\"required\"> <label for=\"form-field-field_1989383-1\">Financial<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-field_1989383-2\" name=\"form_fields[field_1989383]\" required=\"required\"> <label for=\"form-field-field_1989383-2\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d9e0e01 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d9e0e01\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf other, please specify:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d9e0e01]\" id=\"form-field-field_d9e0e01\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7509ccc elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7509ccc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBudget Currency\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"USD\" id=\"form-field-field_7509ccc-0\" name=\"form_fields[field_7509ccc]\" required=\"required\"> <label for=\"form-field-field_7509ccc-0\">USD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"EUR\" id=\"form-field-field_7509ccc-1\" name=\"form_fields[field_7509ccc]\" required=\"required\"> <label for=\"form-field-field_7509ccc-1\">EUR<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"CHF\" id=\"form-field-field_7509ccc-2\" name=\"form_fields[field_7509ccc]\" required=\"required\"> <label for=\"form-field-field_7509ccc-2\">CHF<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-field_7509ccc-3\" name=\"form_fields[field_7509ccc]\" required=\"required\"> <label for=\"form-field-field_7509ccc-3\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_46d8bbd elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_46d8bbd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf other, please specify:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_46d8bbd]\" id=\"form-field-field_46d8bbd\" class=\"elementor-field elementor-size-md  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"en_us\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-57fc59e e-flex e-con-boxed e-con e-parent\" data-id=\"57fc59e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Technology Grant Request Form We believe in the importance of supporting research studies that advance medical and scientific knowledge about our products. All researchers interested in conducting their own study can directly submit a study proposal through the dedicated portal; this will require completing the Helsinn Research Grant Submission Online Form. The proposal will be [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":193,"menu_order":4,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-850","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/pages\/850","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/comments?post=850"}],"version-history":[{"count":109,"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/pages\/850\/revisions"}],"predecessor-version":[{"id":2000,"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/pages\/850\/revisions\/2000"}],"up":[{"embeddable":true,"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/pages\/193"}],"wp:attachment":[{"href":"https:\/\/helsinn.com\/en_us\/wp-json\/wp\/v2\/media?parent=850"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}