INFORMATION REQUEST FORM

Date : 11/23/2009 1:06:32 PM

1. Principal Investigator: First name: Last name:

2. Institution:

   Address:

   City : State: Zip:

3. Phone Number: ( ) -

4. Fax: ( ) -

5. Email:

Research Study Information

1. Title of Research Project:

2. Research Goals : (optional, but description will assist us in processing your request)

IRB Approval: In order to receive the CHIME data, you must obtain approval from your

local IRB. Please provide us a copy of the letter from your IRB for our files.

IRB approval letter from institution provided

Available Data

Survey and accompanying SAS dataset (1 CD)

Please note year(s) of interest ____________

 

* The cost of the storage medium will be the responsibility of the requesting group.

**The DCA C is available to provide additional assistance to extract the variables of interest at an additional cost to the requesting group.