Data Sharing Request Form

Please complete all details in the data sharing request form below and submit. Incomplete forms will not be considered and returned to the requestor. Proposals must be completed in English and will not be reviewed until all information is provided. If a proposal is approved, all parties that will have access to the data per the proposal must sign a data access and use agreement to gain access to the data.

General Information

Has this proposal already been submitted to Ultragenyx?

Yes

Lead Requestor Information

Name

Title

Affiliation/Institution

Address

State/Province

Country

Phone

Email Address

Please provide the name(s) of all Researchers involved in proposal.

Please upload CVs for all researchers involved in the proposal

Drop your files here

For team members without attached CV, please provide a written summary of relevant scientific and statistical experience and expertise.

Research Proposal

Research Proposal Title

Request Reason/Intended Use

Briefly describe in 3000 characters or less the intended use and background information

Objectives (if applicable)

Endpoints (if applicable)

Hypothesis (if applicable)

Data Request Details

Please indicate the data or information requested, list the specific studies, subsets, data fields, and time points being requested.

NCT # or Protocol Title

Enrollment (n=#)

Please provide the reason you have selected this study

Please provide the reason you have selected this study population

Data Fields or Variables

Time Points

Please provide the reason(s) why you have selected these data fields

Does the proposed research require an Ethics Committee or Institutional Review Board (IRB) approval?

Yes

Please indicate how this research plan will be funded.

Please provide full citation or references used above

Data Sharing Plan

Please provide your plan, including estimated timelines, for how you intend to share the results.

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