v02, 12JUN2014
Request to provide data from HOVON trials
Person requesting the use of data:Name: / Role/function:
Institution: / e-mail:
City: / Telephone:
Describe the purpose the data will be used for:
○ Meta analysis○ Research project○ Commercial application (e.g. product development)
○ Other, specify:
Title and short description of the project:
Please include a research proposal / project summary with this document.
Project leader / supervisor:
Name: / Role/function:
Institution: / e-mail:
City: / Telephone:
Will results from the project be published?
○ Journal○ Conference (oral, poster, abstract)○ Other, specify:
○ No, provide reason:
Please provide names of any project partners / affiliates:
Describe the data required:
List HOVON trial(s) and type of data e.g. efficacy data, safety data, MRD data, cytogenetic data, treatment data, etc.
Or include information in an attachment.
I have read and understood the terms and conditions regarding the use of data from HOVON trials as stated on the last page of this document.
To be signed by the project leader / supervisor.
Name / Date / Signature
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v02, 12JUN2014
Request to provide data from HOVON trials
Conditions for the use of data from HOVON trials
- Data provided will only be used for the purpose as described on this request form.
- The recipient of the data will not share the data provided with any third party other than the project partners / affiliates described on this request form and other than for the purpose as described on this request form.
- The HOVON trial(s) that generated the data provided will be referencedin any publications resulting from the use of the data provided.
- The HOVON board will receive a copy of any such publications within a week after the publishing date. The project leader will notify HOVON in case of failure to publish the results.
- The project leader and the recipient of the data are responsible that the project the data provided is used for is in compliance with any applicable laws and regulations.
- The project leader and the recipient of the data are responsible for the scientific quality and validity of the project the data provided is used for.
- Data delivery by HOVON includes the following: selection of the appropriate data and metadata to be provided to the recipient as present in the HOVON database; any required actions to ensure anonymity of the data and ensure patient privacy; conversion of the selected data and metadata in an acceptable format for the recipient.
- Details and planning of the data delivery need to be discussed with the HOVONDataCenter statistician, who will contact the recipient of the data after approval of the request.
- HOVON may charge the recipient for the costs made for data delivery. HOVON will notify the recipient of this in advance.
- If the recipient whishes any further processing of the data or analysis of the data prior to delivery, this needs to be agreed upon separately with the HOVON Data Center. The HOVONDataCenter may charge a fee for the services provided.
Please send a copy of the signed formby fax or e-mail together with a research proposal / project summary to:
HOVONDataCenter
Fax +31(0)10 70 41 028
To be completed by HOVON executive board if approval to provide data is granted:Name / Date / Signature
If approved, please forward a copy of the signed form to the HOVONDataCenter,
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