Data Sharing Request Submission Form

PROJECT TITLE

DATA SOURCE/STUDY

DATA ELEMENTS BEING REQUESTED

RESEARCH PROPOSAL

METHODS

RESEARCH JUSTIFICATION

RESOURCES/COLLABORATION FROM SPONSOR OR STUDY LEADERSHIP

DISSEMINATION/PUBLICATION PLAN

FUNDING SOURCE (if any)

Name

Email Address

Affiliation and city

Phone Number

Provide any and all real or potentially perceived conflicts of interest related to this research. Include financial interests such as funding, fees, salary or ownership for the investigators and/or their affiliated institutions or employers

Name

Email Address

Affiliation and city

Phone Number

Provide any and all real or potentially perceived conflicts of interest related to this research. Include financial interests such as funding, fees, salary or ownership for the investigators and/or their affiliated institutions or employers

Name

Email Address

Affiliation and city

Phone Number

Provide any and all real or potentially perceived conflicts of interest related to this research. Include financial interests such as funding, fees, salary or ownership for the investigators and/or their affiliated institutions or employers

If yes, explain

My account

Data Sharing Request Submission Form