Clinical Data Sharing Request Form

Clinical Data Sharing Request Form

Section 1: Primary Researcher Information

Required fields are marked with an (*)

Name*

Affiliation / Institution

Email*

Address

City

State / Province

Country

Postal / Zip code

Curriculum Vitae (CV)*

Check to confirm your CV has been uploaded in the Attachments section below

Yes

Conflict of Interest Disclosure*

Check to confirm the COI form has been uploaded in the Attachments section below

Yes

Section 2: Research Project Information

Required fields are marked with an (*)

Jazz Product(s) Name*

Study Name (if multiple studies, list all)*

You may also add Protocol Number or NCT Number

Research Proposal Title*

Research Background / Rationale*

Include details as to how this research will contribute to an unmet medical need or bridge a gap in medical knowledge

Research Objective(s) and Endpoint(s)*

Include any hypotheses that will be tested. You can upload your research plan in the Attachments section below

Data and / or Document(s) Requested

Data Analysis Plan*

Yes

No, will be provided later

Publication Plan*

Yes

No, will be provided later

Section 3: Research Team Information

Required fields are marked with an (*)

Names of All Researchers Requesting Data Access*

Provide the names of all team members who will require access to the data for analysis

Conflict of Interest Disclosure for Research Team*

Check to confirm the COI form has been uploaded in the Attachments section below

Yes

Curriculum Vitae for Research Team*

Check to confirm that CVs for the research team have been uploaded in the Attachments section below

Yes

Section 4: Attachment

Attach all required/supporting documents here

File Upload*

Drag and drop files here or

Privacy Agreement*

“You understand and agree that any personal information you provide through this form will be processed by Jazz Pharmaceuticals in accordance with Jazz Pharmaceuticals’ Privacy Statement (https://www.jazzpharma.com/privacy-statement/ ). Such personal information will be processed by Jazz Pharmaceuticals only for the specific purpose of reviewing your request. Please do not provide any sensitive personal information.”

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