REQUEST TO CONTACT REGISTRANTS APPLICATION FORM
Instructions: Please complete the following information and attach any relevant supporting documentation.
RESEARCHER DETAILS
Researcher name:
Organisation:
Department or division name:
Address :
Suburb/Town
State/territory:
Postcode:
Phone:
Email address:
AIMS OF STUDY
Please provide the aims and objectives of the study, expected outcomes and benefits for people living
with diabetes or those at risk.
ETHICS COMMITTEE APPROVALS
Please provide a copy of all ethics committee approvals with this application.
Comments:
DETAILS OF PERSONS WHO WILL ACCESS AND USE THE NDSS INFORMATION
Name:
Position title:
Name:
Position title:
Name:
Position title:
Name:
Position title:
PROPOSED TIMELINE OF STUDY AND COMPLETION DATE
Please detail the proposed timeline of the study (if attaching a document please advise this in the comments
section below).
Comments:
Please advise the proposed completion date : Date:
PROPOSED LETTER TO REGISTRANT, INCLUDING THE RESEARCHER’S CONTACT INFORMATION &
FORMS FOR REGISTRANTS TO CONSENT TO RESEARCH
Please attach copies to this application.
Comments:
PROPOSED SURVEY/QUESTIONNAIRE
Please attach copies of any surveys/questionnaires to be provided to research participants, including
advice to participants as to how participants will be provided with feedback on the outcomes and results.
Comments:
OUTLINE OF INFORMATION REQUESTED
For example the number of participants required for the study, age range, gender, type of diabetes (and
any other information such as method of management whether insulin or non-insulin treated), postcode,
state, etc.
If requesting postcode information, please provide the postcodes required in an Excel format.
To discuss your data needs, please contact the Privacy Officer on 02 6232 3800.
Comments:
DATA REQUEST APPLICATION FORM
Instructions: Please complete the following information and attach any relevant supporting documentation.
APPLICANT DETAILS
Applicant name:
Organisation:
Department or division name:
Address :
Suburb/Town
State/territory:
Phone:
Email address:
Postcode:
DATA EXTRACT REASON
Provide an outline of reason for requesting NDSS data and ethics approvals (if appropriate)
Comments:
DETAILS OF DATA EXTRACT
For example, age range, gender, type of diabetes (and any other information such as method of
management whether insulin or non-insulin treated), postcode, state, etc.
If requesting postcode information, please provide the postcodes required in an Excel format.
To discuss your data needs, please contact the Privacy Officer on 02 6232 3800.
Comments:
DATE DATA REQUIRED (allow a minimum of 10 business days; complex extracts may take longer)
Date:
REPORTING
I agree to provide Diabetes Australia with the final draft report and a copy of the final report or published article.
Applicant Name:
Applicant Signature:
Date:
DATA ACKNOWLEDGEMENT AGREEMENT
I Agree that any use of the data provided will include the following acknowledgement text::
“This data was sourced from the National Diabetes Services Scheme (NDSS) – an initiative of the
Australian Government administered by Diabetes Australia since 1987. Through the NDSS, Diabetes
Australia provides diabetes self-management products and support services to over one million
Australians with diabetes.”
Applicant Name:
Applicant Signature:
Date:
SUBMISSION INSTRUCTIONS
Send your application addressed to:
The Privacy Officer, NDSS, Diabetes Australia
Email: ndss@diabetesaustralia.com.au
Post:
GPO Box 3156, Canberra ACT 2601
Fax:
02 6230 1535
OFFICE USE ONLY:
Date Received:
Received by:
Request Register Number:
Approval by:
Position title:
Signature:
Date: __/__/____
REPORTING
I agree to provide Diabetes Australia with study status reports as requested, draft reports and a copy of final
research study report or published article.
Applicant Name:
Applicant Signature:
Date:
DATA ACKNOWLEDGEMENT AGREEMENT
I agree that any use of the data provided will include the following acknowledgement text:
“This data was sourced from the National Diabetes Services Scheme (NDSS) – an initiative of the
Australian Government administered by Diabetes Australia since 1987. Through the NDSS, Diabetes
Australia provides diabetes products and self-management support services to over one million
Australians with diabetes.”
Final draft reports must be provided to Diabetes Australia for approval of acknowledgement text and
presentation.
Applicant Name:
Applicant Signature:
Date:
SUBMISSION INSTRUCTIONS
Send your application addressed to:
The Privacy Officer, NDSS, Diabetes Australia
Email: ndss@diabetesaustralia.com.au
Post:
GPO Box 3156, Canberra ACT 2601
Fax:
02 6230 1535
OFFICE USE ONLY:
Date Received:
Received by:
Request Register Number:
Approval by:
Position title:
Signature:
Date: __/__/____