Limited Data Analysis Request Form

REQUESTER INFORMATION*
Requestor Contact*

Full Name and Credentials (e.g. John Smith, MD)

Affiliation

EmailPhone

Postal / Zip Code
Requestor Address*

Street Address

Street Address Line 2

CityState

Zip Code
Requestor Role*

Anesthesiologist (active or retired)Resident/FellowOther
ASA Member #*
Enter NA if non-member
Do you plan to include a mentor for this request?*

YesNo
CONFLICT OF INTEREST: Within the last 5 years, do you or your mentor have any financial interest in or funding to disclose? If yes, explain below:*
Enter "No conflicts" if nothing to disclose
Upload Requestor CV:*

Cancelof

STATEMENT OF COMPLIANCE*
By signing below, I attest that I have completely disclosed all of my intended uses for the requested data above. I understand that data provided by AQI pursuant to this data request is intended solely for my use, and disclosure to anyone besides my listed ASA member mentor is strictly prohibited unless expressly agreed to in writing by AQI. I further understand that I am responsible for obtaining IRB approval before receiving any data from AQI if required by my institution. I will agree (and my ASA member mentor will agree) to adhere to the terms of a Data Use Agreement with AQI and AQI’s Data Use Policy if my request for data is approved.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
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