Data requests

What service would you like VCR to provide

Aggregated summary statistical report (e.g. summary data presented in tables)
Detailed report with each patient presented on an individual line
Identifiable patient-level data
Data linkage
Other

Contact person details

First name

Last name

Organisation / Institution

Division (if applicable) (optional)

Address

Suburb

Postcode

State / Territory (optional)

Country

Email address

Mobile phone (optional)

Landline phone (optional)

Primary purpose of data request- what will it be used for? (Required) (optional)

If other, please provide further detail below (optional)

Brief project description

Project title

Brief project description - what do you want to do?

Please include aims and hypotheses (one paragraph or no more than 500 words).

Who do you anticipate will have access to the output of this work? (Required)

If other, please provide further detail below (optional)

When do you need the data? (optional)

Reason for data urgency? (optional)

Lead Investigator details

Click here if the lead investigator is the same as the contact person (optional)

First name (optional)

Last name (optional)

Organisation (optional)

Division (if applicable) (optional)

Address (optional)

Suburb (optional)

Postcode (optional)

State / Territory (optional)

Country (optional)

Email address (optional)

Phone mobile (optional)

Landline phone (optional)

Ethical review

Status of Ethics review (optional)

Approved
Pending
Yet to be submitted

Primary Ethics Committee reviewing the application (optional)

(Please list)

HREC approval ID (optional)

Date ethics certificate obtained (optional)

Attachments

Attachments should be one of these types: PDF, DOC, DOCX, XLS, XLSX, TXT, JPG, GIF, PNG and less the 3MB each.

Protocol (optional)

(including data analysis plan)

Ethics approval certificate (optional)

Ethics submission forms (optional)

Any relevant documents to support this application (optional)