REQUEST FOR TRANSLATIONS
1. Date of the request: / [DATE]2. References: / MRT’s reference: [REF]
User’s study reference/ protocol number (if any): [REF]
3. User: / User Name (hereinafter referred to as “User”): [complete the name of the individual or of the company]
Legal form : [individual or company’s legal form]
Address : [personal address or address of registered office]
Country :
Name of the contact in charge of this request:
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Addressee:
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4. Provider: / Mapi Research Trust (hereinafter referred to as “MRT”)
Information Support Unit
27 rue de la Villette
69003 Lyon
France
Telephone: +33 (0)4 72 13 65 75
Fax: +33 (0)4 72 13 66 82
5. Questionnaire needed: / Scleroderma Health Assessment Questionnaire (hereinafter referred to as “the Questionnaire” or “the SHAQ”)
[the SHAQ is composed of the HAQ-DI and of several additional VAS referenced as “Scleroderma VAS”]
6. Bibliographic reference: / Steen VS, Medsger TA (1997) The value of the Health Assessment Questionnaire and special patient-generated scales to demonstrate change in systemic sclerosis patients over time. Arthritis Rheum 40:1984–1991
Bruce B and Fries J. The Stanford Health assessment Questionnaire (HAQ):A review of its history, issues, progress and documentation. J Rheumatol 2003;30(1):167-78
Ramey DR, Fries JF, Singh G. The Health Assessment Questionnaire 1995-status and review. In: Quality of Life and pharmacoeconomics in clinical trials. Second edition. Edited by B Spilker. Lippincott-Raven Publishers, Philadelphia, 1996
Fries JF. The hierarchy of quality-of-life assessment, the Health Assessment Questionnaire (HAQ), and issues mandating development of a toxicity index. Control Clin Trials 1991; 12:106S-17S
Fries JF. The Assessment of disability: from first to future principles. British Journal of Rheumatology. 1983:(22)Supplement:48-58
Fries JF, Spitz PW, Young DY. The dimensions of health outcomes: the health assessment questionnaire, disability and pain scales. J Rheumatol. 1982 Sep-Oct;9(5):789-93
Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum 1980; 23:137-45
7. Service: / Delivery of translations
8. Language version(s) needed: / · LIST OF
· LANGUAGE
· VERSIONS
Translations may not have undergone a full linguistic validation methodology. The level of translation for each scale should be verified.
9. Copyright ownership
and conditions of use of the Questionnaire: / a. Copyright ownership:
The copyright on the HAQ is held by Stanford University. The Scleroderma VAS are in the public domain.
b. Conditions of use:
The Questionnaire can be used without specific permission from its developer/copyright owner and the translations can be obtained from MRT.
User is not allowed to modify the translations provided by MRT.
In case of publication, User shall acknowledge the source bibliographic reference.
10. Responsibilities: / Mapi Research Trust may not be held liable for the consequences resulting from the use of the translations provided by Mapi Research Trust.
11. MRT’s Access fees : / o Commercial users (Industry, CRO, any for-profit companies):
750 Euros excluding VAT per available translation
o Funded Academic users (Projects receiving funding from commerce, government, EU or registered charity):
100 Euros excluding VAT per available translation
o Academic Users (Projects not explicitly funded, but funding comes from overall departmental funds or from the University or individual funds):
free
Total amount: [total amount to be indicated] Euros
12. Payment Schedule and Terms of Payment: / The User may pay the price by bank transfer, cheque or bank card.
The User undertakes to pay the amounts due within a period of thirty (30) days from the date of the invoice.
13. Timeline: / The translations will be provided upon receipt of the payment by MRT
Agreed and accepted at the date of execution hereof by:
User:
Name:
Date:
Signature:
SHAQ_UA_Shortversion_August2016