Data Request Form

To request data from MEASURE Evaluation, please complete this form.

Which MEASURE Evaluation data are you requesting?

Study name ■

Type complete citation of study

Study year ■

Study principal investigator (PI) ■

MEASURE Evaluation requirements

Please note - MEASURE Evaluation requires that: * Analysis will be limited to aggregate statistics. * Given it may be known which facilities or providers participated in the study, it may be possible to deduce the identities of study participants. The institution will agree to use these data only for analysis purposes and not take actions to identify individuals or institutions. * Health facilities or providers are not identified in publications, reports or presentations either directly or indirectly. * Data not be shared with others outside your research team, or used beyond the purpose(s) outlined above without informing the project. * Any publications, presentations or reports resulting from the analysis will be communicated to MEASURE Evaluation (please see the contact below). * MEASURE Evaluation is acknowledged in all reports based on these data. * The recipient be aware these data are being released ‘as is’ and the PI for the original study may or may not be able to assist with data queries. Should you have questions regarding this agreement please contact: Rick O'Hara, Programmer Analyst, MEASURE Evaluation, rjohara@email.unc.edu, (919) 966-1720

The following contact information of the PI of your project is required.

PI name ■

Organization ■

Address ■

Country ■

Select your country from the pull-down list.

Business telephone ■

E-mail address ■

Facsimile

Statement of purpose ■

Please describe the proposed use of the data. If there is an existing proposal or study protocol, please submit it with this form and only provide a brief summary below.

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Existing proposal or study protocol

Upload here.

Certification by principal investigator

By submitting this application, the PI certifies that the information provided above is true and agrees to the data use requirements listed above.