ACHQC Foundation Partner Data Request Form

ACHQC Foundation Partner Data Request Form

Participating Foundation Partner Request for Data
Name*

First NameLast NameDegree
Name of the Associated Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Brief Project Proposal (list study population, comparison groups, primary outcome measure, and confounding factors)*
Type of Data Requested*

Patient-level de-identified data (to be analyzed by your local team/analyst)Summary analyzed data performed by the ACHQC analytic team
How you will use data reports (check all that apply)?*

Internal UseExternal Use (e.g. marketing, promotion, training, educational activities)Regulatory SupportReimbursement SupportPublicationOther
Please type your full name and title to sign before submitting your request.*
Upon receipt, each project will be reviewed and a scope of work with deliverables, timeline and detailed quotation will be provided back to the requester for acceptance prior to any project initiation. Data reports will be provided under the terms of a written Data Use Agreement that must signed before data reports are delivered..
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