Clone of GTC Prospective Hospital Membership

Request Form for GTC Data for Publication or Presentation
Please complete this form if your project involves:
- Use of aggregate GTC data
- Use of data from other institutions
- Comparative analysis with GTC benchmarks
This form is not required for projects limited to your own institution's data.
1. Project Information:
Proposed Project Title*
Principal Investigator(s) Information:
Full Name*
Affiliation(s)*
Email(s)*
example@example.com
Phone Number(s)*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to GTC (e.g., site PI, GTC committee member):*
2. Study Description:
Please describe the proposed project:
- Specific hypothesis or question
- GTC data requested (e.g., time period, patient population)
- Methods of analysi
- Anticipated conclusions or outcomes
Project Description*
Upload Additional documents if necessary

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3. Target Dissemination:
- Intended journal(s):
- Target conference(s):
- Anticipated submission date(s):
GTC recognizes these may change over time.
Please explain:*
4. Proposed Authorship:
Please list proposed authors, including their:
- Name
- Affiliation
- Relationship to GTC
- Contribution to the project
Author(s)*
GTC must be listed as a group author (Please review Global Tracheostomy Collaborative Publication and Presentation Policy)

• GTC reserves the right to designate specific contributors (e.g., Database Coordinator, Steering Committee members)
• Final authorship must follow ICMJE criteria

Author Name, Affiliation, GTC Role, Contribution
5. Data Privacy and Security:
GTC data must remain within secure institutional environments (e.g., HIPAA, GDPR-compliant systems).
Where will the Data be stored?*
Describe how data will be protected (e.g., institutional firewall, restricted access):*
6. IRB / Ethics Approval:
IRB or Ethics Board Name:*
Not yet submittedSubmitted (pending)Approved
Date of anticipated approval:
7. Intent to Publish:
Yes, peer-reviewed publicationYes, conference abstract/presentationNo, internal analysis only
If yes, where?
8. Acknowledgment and Agreement:
We have reviewed the GTC Publication and Presentation PolicyThe project will conform to all applicable privacy laws (e.g., HIPAA, GDPR).GTC data will only be used for the approved project described above.No patient-level data will be accessed by anyone not listed as a co-investigator and approved by GTC.Group authorship and designated contributors (e.g., Database Coordinator) will be honored per GTC guidance.The GTC Publication Committee must review and approve the final manuscript or presentation prior to external submission.Preliminary findings may not be shared in public forums unless approved by GTC.
Signature
Full Name
Date

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Request Form for GTC Data for Publication or Presentation