Registration Form

All sections and versions of the HLQ are copyrighted and may only be used with permission from the authors;this includes translation of the HLQ into other languages. A database of registered HLQ users is maintained to ensure that copyright is not breached. To be able to use the HLQ, you will need to obtain a licence from Deakin University. To obtain a licence,please complete the registration form below.

Alicence processing fee of AUD250 (plus GST for Australian users) must be paid.

Completetheformandreturnitto.

PleaseNote:alicencerequestcannotbegeneratedwithout a fully completed form

  1. Chief Investigator responsible for the project / supervisor of student

(Title, full name, full address, email)
  1. Authorised officer (person who can authorise payment and sign licence agreement on behalf of theorganisation seeking a licence)

Title:
Full name:
Name of entity for licence*:
ABN (or relevant business registration number):
Address:
Country:
Email*:
Website:
Phone number:

* Important: The HLQ licence can only be issued to an organisation, a legal entity, not an individual and non-institutional email addresses are not acceptable.That is, the application will be rejected ifgmail, yahoo or other non-institutional emails are provided.

  1. Type of organisation (tick all that apply):

Hospital/Medical Practice
Research organisation (University or Institute)
Commercial organisation
Other (please specify):
  1. List of other investigators/student:

(Title, full name, address, email)
1.
2.
  1. Student waiver:

If the use of the HLQ is exclusively for a single Masters or PhD student project, the supervisor may apply for a licence fee discount. Evidence of studentship must be provided by an institutional representative.

  1. Describe the project where the HLQwill be used

Name of project:
Design, subjects, disease type, intervention, methods:
7. / Start date of project:
8. / End date of project:
9. / Project funding (Funding entity / Amount):
10. / a) / Total number of respondentsin study:
b) / Number of administrations per respondent:
c) / Total number of times the HLQ will be administered across study (a x b)*:

* Note: a licence is based on a single project basis. Provide a single total number only.

11.Language*:

EnglishArabicChinese(Simplified)Chinese (Trad)

CzechDanishDutchFrench (France)

French (Canada)GermanGreekHindi

IndonesianItalian MalaysianNorwegian

Portuguese (Brazil) Romanian Slovak Somali Spanish (Argentina) Spanish (Spain) Vietnamese Yoruba (Nigeria)

Other (list):

*Note: Additional languages may be available – contact slation and adaptation can only be done under licence and in collaboration with Deakin University using the HLQ translation protocol. Conditions and fees apply.

12.For the purposes of building an international community of practice, are you willing for the Investigator’s contact details to be made available to other organisations or researchers working in a similar field, region or language?

YesNo

13.We are conducting research into the sensitivity, validity and reliability of the HLQ, and aim to provide benchmarks for the HLQ to assist researchers and organisations to understand their results. Are you willing to be contacted about participating in these research and development projects?

YesNo

Please ensure that all information provided above is valid and accurate as they will used for the issuance of your HLQ licence agreement.

TheHealthLiteracyQuestionnaire(HLQ).©Copyright2014DeakinUniversity.Authors:RichardH Osborne,RachelleBuchbinder,

RoyBatterham,GeraldR Elsworth.NopartoftheHLQcanbereproduced,copied,altered or translatedwithoutthepermissionoftheauthors.

Furtherinformation:

Updated October 2015 1