Healthcare Collaborative Project Proposal

"*" indicates required fields

Salutation

First Name *

Last Name *

Credentials

Title *

Email *

Phone *

Mobile

Fax

Organization Name *

Organization Street Address

Organization City

Organization State/Province

Organization Zip/Postal Code

Project Title *

Brief description of needs for data and intent of the project *

Brief description of how the proposed project supports the NHC mission *

a. Identify if the request is a de-identified or limited data set *

b. Timeline for expectation of receipt of data *

Participant Resources