Scored Patient-Generated Subjective Global Assessment© (PG-SGA),
PG-SGA Short Form© (PG-SGA SF) and the Pt-Global© Multilingual Research and Clinical app
Permission Request Form
Personal Information (person requesting permission, principal investigator)
Name:
Title:
Organization:
Address:
Country:
Phone:
Fax:
Email:
Date of completing this form (dd-mm-yy):
1. Purpose for the use of the PG-SGA:
Electronic Medical/Health Record, please specify: ______
Education
Health practice internal study
Research:
Clinical trial (circle): Phase I Phase II Phase III
Observational research initiative - please specify: ______
Psychological Intervention
Symptom Management
Other, please specify: ______
Publication, please specify: ______
Other, please specify: ______
2. Title of Project/Publication:
3. Please give a concise overview of the project, describing the Aim/Objective, Study Design, Methods and other relevant information:
4. Version and language of PG-SGA to be used:
a. Version:
PG-SGA full version, please specify version date: ______
PG-SGA Short Form, please specify version date: ______
Pt-Global app/web tool
b. Language version of PG-SGA to be used:
English metric
English non-metric
Dutch
Portuguese
Thai
Other (please specify language): ______
5. Method of completing the PG-SGA in the project:
Patient completes Boxes 1 – 4
Patient completes Boxes 1 – 4 and health care professional completes Worksheets 1 – 5
Health care professional completes Boxes 1 – 4 and Worksheets 1 – 5
6. If you have already done the research, did you make any modifications on the PG-SGA form? If so, please specify.
No
Yes, I made the following changes: ______
7. Funding source, if applicable:
8. Expected or actual study start date (dd-mm-yy):
9. Expected or actual study end date (dd-mm-yy):
10. Scheduled number of PG-SGAs per patient: ______
11. Please specify assessment schedule, if greater than 1:
Weekly
Monthly
Bi-monthly
Quarterly
Semi-annually
Annually
Other please specify: ______
12. Total number of expected or actual patients:
13. Patient inclusion (diagnosis and stage type):
14. Type of organization:
Academic Institution
Continuing Education Provider
Clinic
Medical Communications Firm
Outcomes Research Organization
Pharmaceutical Firm
Private Practice
Publisher
Other, please specify:______
15. Have you written any abstracts or manuscripts etc. including the use of the PG-SGA?
Yes
No
If yes, please list title of each publication and send copies to the address below.
1. ______
2. ______
3. ______
If you need permission from Pt-Global beyond email notification, please include information regarding to whom the permission letter should be addressed.
Name:
Title:
Organization:
Address:
Phone:
Fax:
Email:
Faith D. Ottery, MD, PhD, FACN
Ottery & Associates, LLC.
1145 Museum Blvd, #411
Vernon Hills, IL 60061
Phone +001-215-694-1600
V0.8.2018