Research Request for ToxIC Data

Fill out this form if you want to use data from the ToxIC Core Registry or the ToxIC Snakebite Subregistry for research, including for abstract submissions or manuscripts.

Please allow 2-3 weeks for review.

Date of Form Entry

mm/dd/yyyy

Primary Investigator Last Name

Primary Investigator First Name

Primary Investigator Email

Mentor/ToxIC PI Last Name

Mentor/ToxIC PI First Name

Mentor/ToxIC PI Email

Names of Other Co-Authors

ToxIC Site

If Other ToxIC Site - Please specify which site

Which ToxIC database is this study for?

Title of Project

Description of proposed study (minimum of one paragraph) including background and rationale,

Primary and Secondary Aims

Primary and Secondary Outcome

Keywords for study (such as drug or population of interest)

Inclusion Criteria

Exclusion Criteria

Basic Inclusion Criteria - Used to define/limit the Cases in the Data Set

Basic data form elements are available here

Years Included

Age range for study

Ages include unknown?

Sex

Encounter Type

Encounter Type - Other Specify

Exposure Type

Exposure Class

Choose class or classes desired (multiple-choice)

Lists of agents within each class are available here

Exposure Agent (generic name) - Add specific agents of interest if applicable

Lists of agents within each class are available here

Single and/or Multiple Agents?

Clinical Signs

Clinical Signs detail (If applicable)

Treatment Category

Treatment detail (If applicable)

If research is to be presented as an abstract, please specify which professional meeting (Example: NACCT 2022 or ASM 2022). "NA" if not applicable

I agree that I will add the last author as "On behalf of the Toxicology Investigators Consortium" on all abstracts, posters, or publications.

I agree that I will submit all manuscripts to toxic@acmt.net for approval prior to journal submission

Send me a copy of my responses

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