Pre-Agreement Form

WLQ-SF_User Agreement

WLQ-SF

Pre-Agreement Form

Before issuing the User Agreement that will allow you to use the WLQ-SF (the “Questionnaire”), please complete the following information:

I.Identification of the User

User Name:
Legal form: [individual or company’s legal form]
Address:......
Country:
Name of the contact in charge of the Agreement:......
Telephone number: ...... Fax number:......
Email address:......
If different:
Legal form: [individual or company’s legal form]
Address:[personal address or address of registered office]......
Country:......
Billing address (if applicable):......
VAT number (if applicable): ......
Addressee:......
PO number or internal reference (if applicable): ......

II. Context of the use of the Questionnaire

Choose between the 3 options:

Option 1Individual clinical practice (please go directly to section 2.02)

Planned term of use:

......

Number of patients expected: ......

Option 2Clinical project or study

Title: / ......
Study/protocol reference: / ......
Disease or condition: / ......
Type of research: / clinical trial:
Phase II
Phase III
Phase IV, post marketing studies, epidemiologic/observational
Program evaluation
Employee health assessment survey
Other: …………………………………………………………………………………………………
Questionnaire used as primary end point: /  yes
no
Number of patients or employed persons expected: / ......
Number of submissions to the Questionnaire for each patient: / ......
Term of clinical follow-up for each patient: / ......
Planned term for project: / start (month/year):......
end (month/year):......
Mode of Administration: /  paper
electronic
telephone
If electronic administration, please indicate mode of data collection:
Use of IT Company (e-vendor): / Hand held device – specify device: …………………………………………………………………………..
Interactive Voice Response (IVR)– specify: ……………………………………………………………
 Web - specify website:………………………………………………………………………………..
Digital Pen - specify device:……………………………………………………………………………………
Tablet - specify device:………………………………………………………………………………..
 other - specify:………………………………….………………………………………………..
 no
 yes – name of IT company and contact:……………………………………………….

Option 3Other project

Title: / ......
Disease or condition: / ......
Planned term of use: / start (month/year):......
end (month/year):......
Description of the project: / ......
......
......
Presentation format of project: / ......

III.Countriesand Languages

MRTgrants the Limited Rights to use the Questionnaire on the following countriesand in the languages indicated in the table below:

Please indicate Stated Purpose Country and Language:

Language: / For use in the following country / Language: / For use in the following country / Language: / For use in the following country
e.g. English / US

IV.Price and payment terms

The User undertakes in relation to MRT to pay the price owed in return for the availability of the Questionnaire, according to the prices set out below, depending on the languages requested and the costs of using the Questionnaire.

WLQ-SF user fees include owner’s royalty feesAND MRT administration and processing fees:

(1)Owner’s royalty fees

Choose between the 4 options below

Option 1 – If the User is a Research Institution ornonprofit organization

The Questionnaire is available to the User for purposes of internal research or academic research only for no fee in return for data sharing when appropriate. The data arising from the use of the Questionnaire by the User (hereinafter, the “Data”) enables the Authors to continually improve their service to the user community. The Data will be de-identified and the Authors agree not to disclose the identity of the data source, or any other characteristics that could be used to reveal the identity of the User or the participants/patients. The Data sharing will be organized directly by the Authors.

Option 2 – If the User is a Commercial entity and for a single use license.

The User agrees to use the Questionnaire for the Stated Purpose only. If User intends to use the Questionnairefor another purpose (an additional clinical trial, and additional client, etc.), the User shall sign another User Agreement.

Option 2.1: User does not agree to share the Data: The fee to be paid by User is $12,000 per use.

Option 2.2: User agrees to share the Data. The fee to be paid by User is $8,000 per use if User agrees to share its data with the Authors. The data arising from the use of the Questionnaire by the User (hereinafter, the “Data”) enables the Authors to continually improve their service to the user community. The Data will be de-identified and the Authors agree not to disclose the identity of the data source, or any other characteristics that could be used to reveal the identity of the User or the participants/patients. The Data sharing will be organized directly by the Authors.

Option 3 – If User is Commercial entity and wishes a Multi-Use Annual license:

The User wishes to make the Questionnaire a part of a set or suite of services or instruments that itoffers to various clients and does not want to use the Questionnaire for a single Stated Purpose.

Option 3.1: User does not agree to share the Data. The annual fee to be paid by User is $20,000.

Option 3.2: User agrees to share the Data. The annual fee to be paid by User is $15,000 if User agrees to share its data with the Authors. The data arising from the use of the Questionnaire by the User (hereinafter, the “Data”) enables the Authors to continually improve their service to the user community. The Data will be de-identified and the Authors agree not to disclose the identity of the data source, or any other characteristics that could be used to reveal the identity of the User or the participants/patients. The Data sharing will be organized directly by the Authors.

Option 4 – For other industry supported projects -

For projects that 1) involve for-hire contracts or consulting agreements, 2) do not meet one of the royalty-free conditions (explicitly and entirely grant-funded research projects, student theses or other student projects, or an internal employer project designed to evaluate a health program), and 3) are not commercial projects, such as an industry study by a manufacturer, the fee is $500 per use for industry-supported projects.

(2)MRT Administrative and processing fees

Please note that depending on the above retained option, the following administrative and process feeswill apply:

Option 1 – Research Institution and nonprofit organization: Free

Option 2 – Commercial entity – Single Use License

License fee per study: $1,500 USD + an additional fee of $ 600 per language version

Option 3 – Commercial entity – Multi-Use Annual License

Annual license of $ 1,500 USD + an additional one-off fee of $600 per language version. User will be billed annually for this license.

Option 4 - Other industry supported projects

License fee per project: $350 + an additional fee of $75 per language version

* excluding VAT

Thank you for completing the WLQ-SFPre-Agreement Form.

We will issue the User Agreement Special Terms based on the information provided.

WLQ-SF_Pre-Agreement_Form_2 0_Feb2018_Protected.docx

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