ACR Learning Network Publication and Data Access Request Form

ACR Learning Network Publication and Data Access Request Form

Project Title

Project Authors

Requestor Information

Requestor Name

Requestor Title

Requestor Phone Number

Phone

Requestor Email

Requestor Organization

Collaborative Participated

If you did not participate in a collaborative, which collaborative are you requesting data or presentation for?

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Cohort Participated

If you did not participate in a cohort, please select N/A.

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I would like to request review and approval of my:

Publication

Presentation

Data Access Request

What information are you sharing?

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Background/Rationale

Need data from us?

Yes

Information Requested

Attach additional information, e.g., list of data elements, table specifications, and sample tables to this request

Desired Date for Publication/Presentation Review or Receipt of Analysis

Target Audience

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Dissemination Plans

Project Funding Type and Name, if applicable

Additional Comments

File Upload

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Send me a copy of my responses