INSTRUCTIONS: Please provide the following information. Additional information may be attached to this form. Please note that only one application per research project is required. However, separate Data Protection Plans and Data Use Agreements are required for each organization represented by the research team.
1. Applicant information: (Note: Unless otherwise instructed, the first Principal Investigator listed will serve as the primary contact person with ICPSR.)
Name of Principal Investigator:
Title:
Department (if applicable):
Organization:
Street Address:
City, State, ZIP:
Phone:
Fax:
Email:
Name of Co-Principal Investigator (if applicable):
Title:
Department (if applicable):
Organization:
Street Address:
City, State, Zip:
Phone:
Fax:
Email:
Please provide information on additional Co-Principal Investigators,
if applicable.
2. Title of research project for which the CTS Physician Survey, 1996-1997
restricted data file is requested.
3. Short description of research project including research
questions, primary methodology, categories of variables to be used
(attach additional sheets if required).
4. What types of data from other sources
will be merged with the CTS Physician Survey, 1996-1997 restricted
data file?
5. State reasons why
the CTS Physician Survey, 1996-1997 public use data file is not adequate for
conduct of the research project.
6. Describe all the ways that you intend to use
the results of the research, including plans for public
dissemination.
7. Provide names, titles, and affiliations of other members of
the research team who will have access to the restricted data or to
output derived from these data. If not all members have been
selected, please list as "unassigned" and indicate the job
titles. Include individuals who are employed by different
organizations.
8. If employed
at an organization that has a current NIH Multiple Project
Assurances (MPA) Certification Number or Federal Wide Assurances (FWA)
Certification Number, please provide the number and expiration
date.
9. If a member of the proposed research team, including subcontractors, is employed at an organization that does not have an NIH Multiple Project Assurances (MPA) Certification Number or Federal Wide Assurances (FWA) Certification Number, please respond to the following questions:
a. Please describe your employer in detail. Include the type of organization,
profit/non-profit status, and primary sources of revenue.
b. What is(are) the
sources(s) of funding for the specific research for which you are
applying to use the CTS Physician Survey, 1996-1997 restricted data file? (List
name of funding organization, whether funds provided as a grant,
contract, or other mechanism.)
c. Please describe proprietary interests of the funding
organizations listed in the response to 9b, above, even if not
directly related to the research project described above.
d. Does your employer have policies regarding scientific integrity and
misconduct, or human subjects research that cover the secondary
analysis of survey data? If so, please describe these policies.
[Data Protection Plan Instructions]
[Restricted Data Use Agreement]
[Supplemental Agreement]
[General Information on CTS Restricted Data]