Industry Data Sharing Request Submission Form

PROJECT INFORMATION

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DATA ELEMENTS BEING REQUESTED

You must provide the date range of the data being requested from the identified dataset. Then be as specific as possible and provide the other details.

  
 
  
 
  
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DATE RANGE
 
 
  
INCLUSION/EXCLUSION RANGES
 
 
 
  
SITES/HOSPITALS
  
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RESEARCH JUSTIFICATION

Provide how this research has scientific merit. Tie-in to how it strengthens the understanding of the study or advances the field of study.

  

RESOURCES/COLLABORATION FROM SPONSOR OR STUDY LEADERSHIP

Identify expected need for assistance from BSC or study personnel beyond delivery of requested dataset. Considerations may include explanation of procedure details beyond the protocol, understanding of past analysis, product details. Note that need for BSC collaboration may impact timeliness of data delivery.)

  

DISSEMINATION/PUBLICATION PLAN AND AUDIENCE

Explain end use of data and intended audience. Example end uses include: presentations, reporting or metrics, comparison with other competitors. Example audiences may include executive committees, clinical research teams, purchasing or marketing departments etc.

   
 
  

  

RESEARCHER INFORMATION

Research Lead

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Co-Lead or Mentors
 
 
 
 
 
 
 
 
 
 
 
 
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 Yes
 No
 
   

   
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 Yes, I certify
  
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