VLCR Data-access-request-form - Victorian Lung Cancer Registry

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RELEASE OF DATA
Application Form
Introduction
The Victorian Lung Cancer Clinical Quality Registry was established in 2011
following a successful grant application to the Victorian Cancer Agency. The
VLCR is housed in the Department of Epidemiology and Preventive Medicine,
Monash University. The VLCR aims to record all newly diagnosed lung cancer
cases in participating sites in Victoria. Information from the registry will be used to
monitor care provided, including treatment, complications and both short and
longer term outcomes of care. This information will be used to help identify trends
and whether gaps exist in service provision.
Victorian Lung Cancer Registry Research
The Victorian Lung Cancer Clinical Quality Registry encourages use of its data for
a variety of purposes such as quality improvement projects, research and clinical
planning. Please refer to the “Data Access and Publication Policy” document for
details.
Instructions
Each request for the release of data must be accompanied by this completed
form. Please type or print clearly.
Please return this completed form along with other required documents (refer to
Data Request Guidelines) to the address below:
Email:
Mail to:
[email protected]
The Victorian Lung Cancer Registry Research Group
School of Public Health and Preventive Medicine / Monash
University
Department of Epidemiology & Preventive Medicine
Level 6 The Alfred Centre
99 Commercial Road
Melbourne Vic 3004
Victorian Lung Cancer Registry Data Access Form July 2014
For any queries relating to VLCR Research, please contact the VLCR Data
custodian:
Dr Sue Evans
Database Custodian
The Victorian Lung Cancer Registry
Department of Epidemiology & Preventive Medicine
Monash University
Email: [email protected]
Ph: +61 3 9903 0017
Fax: +61 3 9903 0556
Website: http://vlcr.registry.org.au/
SECTION A – APPLICANT DETAILS & CONTACT INFORMATION
PRINCIPAL INVESTIGATOR/PROJECT SUPERVISOR:
Title and Name
Appointment
Department
Institution
Mailing Address
Email
Contact Phone No.
Brief description of
the role of this
researcher for this
project
Brief summary of
relevant experience
for this project
Please attach CV to this data request (2 page Max).
ASSOCIATE INVESTIGATOR / STUDENT:
Title and Name
Appointment
Department
Institution
Mailing Address
Email
Contact Phone No.
Victorian Lung Cancer Registry Data Access Form July 2014
Brief description of
the role of this
researcher for this
project
Brief summary of
relevant experience
for this project
Please attach CV to this data request.
ASSOCIATE INVESTIGATOR / STUDENT:
Title and Name
Appointment
Department
Institution
Mailing Address
Email
Contact Phone No.
Brief description of
the role of this
researcher for this
project
Brief summary of
relevant experience
for this project
Please attach CV to this data request.
ASSOCIATE INVESTIGATOR / STUDENT:
Title and Name
Appointment
Department
Institution
Mailing Address
Email
Contact Phone No.
Brief description of
the role of this
researcher for this
project
Brief summary of
relevant experience
Victorian Lung Cancer Registry Data Access Form July 2014
for this project
Please attach CV to this data request.
If there are additional investigators please copy and paste the above tables
and fill out. Please note ALL investigators must be listed.
SECTION B – DATA REQUEST
1.
PURPOSE OF DATA REQUEST?
Research
Clinical
Planning
Business
Other (Specify) ---------------------------------------------------------------------------------
2.
PROJECT TITLE:
3.
WHAT IS YOUR RESEARCH QUESTION / PROPOSAL
(1 page minimum)
This Description should be in the form of an extended Abstract. It should
include at a minimum: Background, Objectives, Methods/Analysis, and
References sections.
Victorian Lung Cancer Registry Data Access Form July 2014
4.
WHAT STATISTICAL ANALYSES ARE REQUIRED FOR THIS
PROPOSAL?
SECTION C – UTILISATION OF DATA
1.
How will you utilise this data? Check all that apply and describe in
detail.
Publications
Details:
Oral
Presentation
Local:
Quality
Assurance
Details:
Student Project
International:
Details:
SECTION D: CHECKLIST
All investigators are listed in section A
All CVs are attached to request
Victorian Lung Cancer Registry Data Access Form July 2014
PRINCIPAL INVESTIGATOR:
NAME:
SIGNATURE:
DATE
Please send completed proforma to the VLCR Team:
Email:
[email protected]
Mail to:
The Victorian Lung Cancer Registry Research Group
School of Public Health and Preventive Medicine / Monash
University
Department of Epidemiology & Preventive Medicine
Level 6 The Alfred Centre
99 Commercial Road
Melbourne Vic 3004
SECTION E – VLCR office use only.
1. Approval
Date:
Approved by:
2. Data Analysis Release
Prepared by:
Date File Used:
File Name:
File Type:
File Location:
Actioned and Released by:
Date:
Victorian Lung Cancer Registry Data Access Form July 2014
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