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Healthcare Collaborative Project Proposal
"
*
" indicates required fields
Personal Information
Salutation
--None--
Mr.
Ms.
Mrs.
Dr.
Prof.
First Name
*
Required
Last Name
*
Required
Credentials
Title
*
Required
Email
*
Required
Phone
*
Required
Mobile
Fax
Organization Information
Organization Name
*
Required
Organization Street Address
Organization City
Organization State/Province
Organization Zip/Postal Code
Project Information
Project Title
*
Required
Proposed Project Overview
Brief description of needs for data and intent of the project
*
Required
Match with Mission
Brief description of how the proposed project supports the NHC mission
*
Required
Data and Timeline
a. Identify if the request is a de-identified or limited data set
*
Required
b. Timeline for expectation of receipt of data
*
Required
Acknowledgement
*
Required
You are strongly encouraged to contact the Collaborative to discuss questions about fit or scope prior to submitting a Collaborative Project Request Form. Once a Collaborative Project Request Form is submitted, a team member will review and determine the following: 1. Match with mission, 2. Project viability, 3. Project appropriateness, 4. Reasonable timeline, and 5. Project category. If upon review, questions arise, staff of the NHC may reach out for further clarification on the project request.
I acknowledge that I have read and understand the
project submission requirements
and that this submission complies with those requirements.