Applicant Information
Full Name
Affiliation / Organization
Email
Phone Number
Project Details
Project Title
Purpose of Data Request
Research Protocol / Proposal Description
Data Details
Requested Clinical Trial Data (e.g., dataset identifiers, trial names, etc.)
Intended Use of Data
Expected Period of Data Use
Data Security Measures
Compliance & Agreements
Ethics Approval / IRB Clearance
Data Use Agreement Required?
Yes
No
Not Sure
Additional Information