Application for Robert Wood Johnson Foundation Employer Health Insurance Survey [Community Tracking Study and State Initiatives in Health Care Reform Program], 1997 Restricted Data File
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 Robert Wood Johnson
Foundation Employer Health Insurance Survey [Community Tracking Study
and State Initiatives in Health Care Reform Program], 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
Robert Wood Johnson Foundation Employer Health Insurance Survey
[Community Tracking Study and State Initiatives in Health Care Reform
Program], 1997 restricted data file?
5. State reasons why the Robert Wood Johnson Foundation Employer Health
Insurance Survey [Community Tracking Study and State Initiatives in
Health Care Reform Program], 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, 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 Robert Wood Johnson Foundation
Employer Health Insurance Survey [Community Tracking Study and State
Initiatives in Health Care Reform Program], 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]
