Patient Registry Data Use Application

Dizziness, Vertigo, and Imbalance Patient Registry – Application for Data Access

If you would like to request data from The Vestibular Disorders Association’s Dizziness, Vertigo & Imbalance Registry for research purposes, please fill out this form. Questions may be directed to The Vestibular Disorders Association’s Research Program Manager, Cynthia Ryan at [email protected]. If you are a medical resident/fellow/physician, you are able to request data. If you are a graduate student or medical student, you will need to have your resident/fellow/attending physician/advisor complete this form to request data, and they can appoint you as the point of contact.

Section One A

Principal investigator must fill out this section.

Name of Principle Investigator(Required)

Prefix First Last Suffix

Please provide your position within organization(Required)

Please provide the name of your organization or institution(Required)

Address(Required)

Please provide the address of your place of work

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Please provide all relevant email addresses where we could contact you

Phone

Please provide you phone number (business and/or primary contact)

Country Phone Number

Please provide the primary researcher’s contact information (name, address etc.) for correspondence(Required)

Please provide the full names of all persons who will have access to the requested data(Required)

Please describe your qualifications(Required)

Section One B

Primary Contact must fill out this section

Name of Primary Contact(Required)

Prefix First Last Suffix

Please provide your position within organization(Required)

Please provide the name of your organization or institution(Required)

Address(Required)

Please provide the address of your place of work

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Please provide all relevant email addresses where we could contact you

Phone(Required)

Please provide you phone number (business and/or primary contact)

Country Phone Number

Please describe your qualifications(Required)

Section Two

Research description

Please provide your proposed project title(Required)

Please provide a brief summary of your proposed project

What are the objectives of your proposed project(Required)

What is your study population’s inclusion/exclusion criteria?(Required)

Please provide us with an explanation for why you are requesting this data

Please estimate the proposed timeline for your proposed study

Section Three

Funding

Do you have data retrieval and preparation funding available?(Required)

Yes

Is your project funded outside of your institution?(Required)

Yes

Section Four

Data security and use

Where will you store the accessed data?(Required)

Indicate physical security features in place to secure against access to unauthorized individuals/organizational safeguards including technical safeguards(Required)

Section Five

Ethics

Is your proposed study already IRB approved?(Required)

Yes

Please provide us with a copy of the approval certificate and a copy of the application and protocol submitted for IRB approval.(Required)

If you have trouble uploading your file, you can email it to [email protected].

Accepted file types: pdf, doc, Max. file size: 128 MB.

Section Six

Defining Registry Data Request

Check one of the following and complete the entry that best describes what you are requesting:(Required)

For the Vestibular Disorders Association to pull Registry data pertaining to a predetermined set of fields and provide it to us (fill in fields below).

For The Vestibular Disorders Association to provide a report that summarizes the data requested

Describe data being requested(Required)

Preferred: Include specific data points (refer to VeDA’s Data Dictionary). Otherwise, describe in general the data you are looking for.

Section Seven

Signatures

Digital Signature of the PI(Required)

Enter your name here.

Digital Signature of the primary contact(Required)

Enter your name here.

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