NRDR Data Analysis Request for Research Publications

NRDR Data Analysis Request for Research Publications

Project Title*

Name of Primary Investigator*

Contact Information

Please provide information for the primary contact for this data request.

Primary Contact

Title

Affiliated Organization

Telephone Number

Email Address*

Co-Investigator(s)

Data Analysis Request Information

The purpose of this form is to help us understand your research and evaluate it for scientific merit and feasibility. Please answer each question. If a question is not applicable, enter NA, but please do not leave blanks.

Registry to be used*

Select or enter value

Research Question*

Background/rationale*

Inclusion/exclusion criteria*

Time frame to be studied*

Relevant registry variables (if known)*

If easier, you can attach a document listing the relevant registry variables.

Desired date for receipt of analysis

Relevant References

File Attachments *Highly Recommended to Streamline Approval Process and Analysis*

Additional information as attachment (e.g. list of data elements from data dictionary, table specifications, sample tables)

Drag and drop files here or

Target Audience and Dissemination Plans

Target Audience

Select or enter value

Dissemination Plans

Please specify the applicable audience: 1.) target publication, 2.) organization and capacity, 3.) meeting including date, or 4.) commercial application.

Project Funding

Select or enter value

Funding Organization Name

Please Make Sure to Click the Box Below to Receive a Copy For Your Records

After submission, if you would like to make edits to your Data Analysis Request or request a status update, please use the link in the confirmation email to contact us. To receive a confirmation email, please be sure to click the box below and provide email address.

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