Database Committee – Request for Application Form

IMPORTANT!

Before you start completing the form, make sure you have all the information required. It is not possible to save a partially completed form for further editing!

Title of the Project *

Principal Investigator/Corresponding Author *

First

Last

Email of the Principal Investigator/Corresponding Author *

Confirm Email

____________________________________________________________________________

Co-Investigators/Co-Authors

Name

First

Last

____________________________________________________________________________

Research Question / Hypothesis *

Rationale and Significance *

Secondary Research Questions *

Patient Population *

Analysis Plan *

Requested Variables *

Disclosures *

____________________________________________________________________________

The Principal Investigator is an active ITMIG member with a membership in good standing*

PI is an active ITMIG member *

If you need to renew your membership CLICK HERE

____________________________________________________________________________

The Principal Investigator has been an active contributor to the ITMIG Databases*

PI has been an active contributor *

"Active contributor" means:

a) Contributor with Data Transfer Agreement (DTA) in place

b) ≥ 20 cases total entered with ≥ 50% completion in the ITMIG database

c) ≥ 5 new cases since 2024

____________________________________________________________________________

All investigators have read and agree with the ITMIG terms of use of the database*

____________________________________________________________________________

Date of Submission *

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Database Committee – Request for Application Form

IMPORTANT!

Co-Investigators/Co-Authors

The Principal Investigator is an active ITMIG member with a membership in good standing*

If you need to renew your membership CLICK HERE

The Principal Investigator has been an active contributor to the ITMIG Databases*

"Active contributor" means:

All investigators have read and agree with the ITMIG terms of use of the database*