2025 UHDRS® & vUHDRS®Request Form

2025 UHDRS® & vUHDRS®

Request Form

The Unified Huntington Disease Rating Scale and revised UHDRS® '99 and accompanying manual (collectively, the “UHDRS®”) and vUHDRS® and accompanying manual (collectively, the “vUHDRS®”) are the copyrighted intellectual property of the Huntington Study Group, Ltd. (“HSG”). The UHDRS®, vUHDRS®, case report forms, and other related materials are copyrighted by the HSG. Individuals, organizations, firms, or other entities seeking to use these tools and/or materials must obtain prior written permission from the HSG. License fees will apply.

REQUESTER INFORMATION

Date of Request:*

Prefix:*

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Requester Name:*

Full Legal Organization Name:*

Address:*

Please include Street, City, Zip Code, Country

Phone Number:*

Email Address:*

Organization Type:*

Please select if you are a Not-for-Profit or For-Profit organization.

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Organization Website:*

HSG Member*

Are you a member of the HSG? If no, become a member here: https://huntingtonstudygroup.org/membership/

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Notices:*

Please provide the name, full physical address, and email address of the contact person at your organization who is responsible for legal notices.

Usage:*

What is your intended use of the UHDRS®? Please describe in detail.

License Type*

Which version of the UHDRS® are you requesting to license?

If you are administering the UHDRS® in person, please select the UHDRS® only option.

If you are in administering the UHDRS® virtually, please select the vUHDRS® only option.

If you are administering the UHDRS® both in person and virtually, please select the UHDRS® & vUHDRS® option.

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Format and Derivative Works (Research)*

Licensee will use the Works in the study / clinic / educational environment in the following manner (select one or more):

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Description (Interactive software / as a service):

Please describe in detail the type of software and or services you will be using for implementation or use of UHDRS®.

Language(s):*

Please list all languages that you request the UHDRS® for:

Environment:*

In what setting will the UHDRS® be administered?

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Environment (Other)*

Please specify in what setting you will be administering the UHDRS®:

CLINIC / EDUCATION

Please complete this section if you are requesting a license for clinical or educational use. If this section does not apply to you then please answer N/A to these questions and move to the next section.

How many patients will be assessed using the UHDRS®?*

Total number.

How many times will the UHDRS® be administered over the term of your license?*

Total number.

Term (Clinic / Education):*

How many years are you planning on assessing your patients for?

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RESEARCH

Please complete this section if you are requesting a license for research or study purposes. If this section does not apply to you then please answer N/A to these questions and move to the next section.

Is this an Investigator initiated study?*

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Are you an HSG Credentialed Investigator?*

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Are you an Early Stage Investigator?

An Early Stage Investigator (ESI) is a new investigator who has completed his or her terminal research degree or medical residency—whichever date is later—within the past 10 years and has not yet competed successfully for a substantial, competing NIH research grant.

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What is the name of the study?*

What is the NCT number? (as applicable)*

What is the Protocol number?*

What is the study phase?*

Will the study/trial be managed through the HSG?*

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Is the study/trial funded?*

Are any industry or commercial sponsors associated with the study?

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Who is your sponsor?*

Location:*

Please list all countries the study is being conducted in:

How many participants will the study have?*

How many times will the UHDRS® be administered over the course of the study?*

Total number.

How many people total will be administering the UHDRS®?*

Total number.

How many sites are participating in this study?*

Start Date*

What is the expected start date of the study/trial?

End Date:*

ADDITIONAL COMMENTS

Additional Information / Questions:*

Any additional information that will be useful in creating a UHDRS® license agreement?

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