International Society for Heart and Lung Transplantation International Heart and Lung Transplant Registry Data/Analysis Request Process All requests for data and/or analysis from the ISHLT heart and Lung Transplant Registry must be submitted using the ISHLT Data/Analysis Request Form (below). ISHLT staff evaluate the request and code it according to one of the below levels. Level 1 requests are simple requests asking for explanation or additional detail about data in Registry reports or requests involving < one hour of time. Individuals submitting Level 1 requests are NOT required to be ISHLT members. Priority of response is given first to Society members, second to non-members who need the information in the treatment of a patient, third to all others. Level 1 requests will be answered on an as received basis within 14 days. Level 2 requests are those requests involving 1- 5 hours of time. Level 2 requests will be fulfilled only for members of the Society who are working at a center which is actively reporting data to the Registry. Level 2 requests will be forwarded to the appropriate Registry Executive Committee member for approval. If approved, Level 2 requests will be answered within 4-6 weeks. Level 3 are those requests involving >5 hours of time. Level 3 requests will be fulfilled only for members of the Society who are working at a center which is actively reporting data to the Registry. Level 3 requests will automatically be placed on the agenda for the next Registry Executive Committee Conference Call for approval. A Registry Executive Committee member will be assigned to consult on each such approved project. For extensive projects, the Registry Executive Committee may choose to recommend that the requestor complete a formal ISHLT Grant application and submit the proposal by the February 15 deadline. The deadlines for submitting Level 3 requests are as follows: January 31, May 31, Sept 30. Individuals requesting any level of data must sign a statement that presentation or publication of this information will be accompanied by acknowledgment of the ISHLT/UNOS International Heart and Lung Transplant Registry as the source of the data. Individuals receiving Level 2 and 3 data will be required to sign an agreement that any written or verbal presentations resulting from the data must be submitted to ISHLT for prior approval. Any publications or abstracts must list the ISHLT/UNOS International Heart and Lung Transplant Registry as a contributing institution and must list at least one Registry Executive Committee member and at least one UNOS staff member as co-authors. The ISHLT Annual Meeting Program Committee and the Journal of Heart and Lung Transplantation have the right of first refusal for abstracts and manuscripts, respectively, generated from Level 2 and 3 data requests. International Society for Heart and Lung Transplantation International Heart and Lung Transplant Registry Data/Analysis Request Form Please PRINT or TYPE. Complete this form in its entirety and return via fax (804-716-0095), email (amanda.rowe@ishlt.org) or mail to Amanda Rowe, ISHLT Data Requests, 9921 Eildonway Place, Richmond, VA 23233. TEL: 804-716-0096. You will receive a reply to your request within 14 days of our receipt of it. Your Name: __________________________________________________________________________ Institution Name: _____________________________________________________________________ Mailing Address: ______________________________________________________________________ Phone: ___________________________________ Fax: __________________________________ Email: ______________________________________________________________________________ Your Profession/Occupation (optional): [ [ [ [ ] ] ] ] Cardio-Thoracic/Vascular Surgeon Nurse/Transplant Coordinator Immunologist Student [ [ [ [ ] ] ] ] Cardiologist Pulmonologist Pathologist Other:______________________________ ISHLT Membership Status: [ ] Member [ ] Non-member Organ(s) for which data is requested [ ] Heart [ ] Lung Data requested is for: [ [ [ ] Heart/Lung ] Worldwide ] United States only; Note: ISHLT does not provide US-only data. Requests for US-only data should be made to datarequests@unos.org) Is data needed for the treatment of a specific individual? [ ] Yes [ ] No If yes, what is your relation to the individual? [ [ [ ] Physician ] Relative ] Other [ [ ] Nurse ] Friend If no, for what purpose is data needed (i.e., manuscript, presentation, general interest, etc.)? _________________________________________________________________________________________ Please describe below that data/information you would like to receive or attach a document that describes your project in detail: Please sign the following statement: I acknowledge that presentation or publication of this information will be accompanied by acknowledgment of the ISHLT/UNOS International Heart and Lung Transplant Registry as the source of the data. Signature: ____________________________________ Date: ___________________________