INFORMATION REQUEST FORM

Date : 11/23/2009 2:43:08 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

Case Report Forms Data (1 CD)

Summary CHIME monitor and PSG databases (1 CD)

Raw physiologic data (600 CDs)

* The data can also be made available on an external hard drive. The cost of the storage medium will be the responsibility of the requesting group. **The DCAC is available to provide additional assistance to extract the variables of interest at an additional cost to the requesting group.