Please Make Copies for Use with Each Submission

BILLING FORM

IF YOU HAVE LOST YOUR DATA PREVIOUSLY PROVIDED, WE REQUEST THAT THIS FORM BE SUBMITTED WITH EACH REQUEST TO RERUN DATA

(Please make copies for use with each submission).

Investigator’s Name:
Hypothesis:
Email Address (Required for WINZIP Attachment – provide 2 addresses):
WINZIP file is sent using Partner’s Secure Transfer. You must login in and pick up your data within 12 days.
If your institution will not receive zipped data files, please provide a home-based PC email address:
In what year did your participants complete the questionnaire?
Billing Name:
Billing Address:
Tax Exempt Number:
Purchase order number: Is your study funded by federal grant? ___Yes ___No
Phone Number:
Email Address:
How will you likely pay your invoice?
Check___
Wire Transfer___ Date of Transfer______
(email Lauren Dougherty: for wire info)
Harvard Internal Payment____
(Harvard Affiliates Only. Email Lauren Dougherty: for account string)
**NOTE: All payments MUST have an identifier in the memo; “Nutrition Dept., T.H. CHAN, Kids” if you use YAQ FFQ or “Nutrition Dept., T.H. CHAN, Adult” if you use 80out, 88GP, grid, or bklt FFQs.

We accept payments by check, wire transfer, or Harvard Internal Payment (Harvard Affiliates only).

Credit cards are not accepted. Email Lauren Dougherty for information if paying by wire or internal transfer.

For billing questions please contact Lauren Dougherty at 617-998-6615 or at

Please make checks payable to Harvard University.

Mail to:

Laura Sampson Kent, MS, RD

Nutrition Questionnaire Service Center

Harvard T. H. Chan School of Public Health

Nutrition, Building 2, 3rd Floor, room 315

665 Huntington Ave

Boston, MA 02115 MEMO: Nutrition Dept., T.H. CHAN, Kids or Nutrition Dept., T.H. CHAN, Adult

SUBMITTING REQUEST FOR RERUN
Number of data sets attached:
List file names:
Please circle the format you would like to receive: EXCEL ASCII
Please circle rate for FFQ type to be rerun:
Rate per Batch
Pink 2007 Booklet / $400* / $1000
Blue 2007 Grid / $400 / $1000
Cherry Original Booklet / $400 / $1000
Purple 88 GP / $400 / $1000
Green 80out / $400 / $1000
Grey Original Kids / $400 / $1000
YAQ / $400 / $1000
Other: / $400 / $1000
*Less than 1000 observations
TWO Email Addresses for Data Return:

List previously analyzed variables to rerun: