CWIS Data Request Form

Data Request Form

CHEST WALL INTERNATION DATABASE (CIID) DATA REQUEST FOR RESEARCH
Prior to approval of access to CWIS Data, the principle investigator must:
- Complete the online Research Request Form, including checking the certification/publication acknowledgement box.
- Provide documentation of either approval or exemption of the study by the investigator’s home institution IRB.
- Complete the online Relevant Financial Relationship Form. Requests that are submitted without completion of the Conflict of Interest Disclosure Form WILL NOT be reviewed.
After all documents are submitted, the project will be reviewed by the Research Committee. Please expect approximately 4 weeks for a decision.
Name

First Name Last Name
Credentials
Example: MD, MBBS, FACS, PhD, PA-C, etc
Preferred email *
example@example.com
Mobile or WhatsApp

Area Code Phone Number
Name of work institution
Are you a current CWIS member?

Yes No
CWIS member sponsor Name

First Name Last Name
CWIS member sponsor preferred email
example@example.com
Please upload a letter from your member sponsor.

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Cancel of

Data Request Form

Study-specific information

Co-investigators (Please list all members who are co-investigators on this research):

	Name and credentials	Email address	CWIS member
Co-investigator 1
Co-investigator 2
Co-investigator 3
Co-investigator 4

Study Title:
Study description document

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Include a brief synopsis of your study proposal, including objective, hypothesis, and methodology Cancel of

Chest Wall Injury Society

Disclosure of Relevant Financial Relationships
A conflict of interest exists when personal activities or relationships interfere (or appear to interfere) with a healthcare professional’s objectivity and judgment in doing what is best for their patient(s) or the operations of the Chest Wall Injury Society.

Please disclose all relevant financial relationships for yourself (and spouse/significant other if applicable) for the previous 12 months. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria for promotional speakers’ bureau, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.

Please note: CWIS considers relationships of the person to include financial relationships of a spouse or partner.
Disclosure

As a reminder, there is no minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship.
Name

First Name Last Name
Do you have any relevant financial relationships to disclose? *

Yes No I am unsure - please contact me to discuss

If you answered yes above, please complete this table on behalf of yourself.

	Relationship	Name of entity/entities
Salary
Royalty
Intellectual property rights
Consulting fee
Honorarium payment for promotional speakers' bureau
Ownership interest (e.g. stocks, stock options, other ownership interests, excluding diversified mutual funds)
Other financial benefits (e.g. employment, management position, independent contractor - including contract researcher, consulting, speaking or teaching, membership on advisory committees or review panels, board membership, other activities from which remuneration is received or expected)

Does your spouse/significant other have any relevant financial relationships to disclose? *

Yes No I am unsure - please contact me to discuss

If you answered yes above, please complete this table on behalf of your spouse/significant other (if applicable).

	Relationship	Name of entity/entities
Salary
Royalty
Intellectual property rights
Consulting fee
Honorarium payment for promotional speakers' bureau
Ownership interest (e.g. stocks, stock options, other ownership interests, excluding diversified mutual funds)
Other financial benefits (e.g. employment, management position, independent contractor - including contract researcher, consulting, speaking or teaching, membership on advisory committees or review panels, board membership, other activities from which remuneration is received or expected)

Attestation

By electronically signing my name below, I am indicating the above notation is the full and complete disclosure of current relevant financial relationships for myself (and my spouse/significant other, if applicable) and for the previous 12 months.
Comments
Electronic signature

Clear
Today's Date

Month Day Year
Date
Questions?

If you have any questions, please email CWIS at information@cwisociety.org.
Should be Empty:

Data Request Form

Data Request Form

Chest Wall Injury Society

Disclosure

Attestation

Questions?