Data request for ADDITION Cambridge
(please send to datasharing@mrc-epid.cam.ac.uk)		

<<Request ID>>

[Entered by Study Coordinator]

Request Date:			__ / __ / __		
Date Data required by:	__ / __ / __
Requested by:	Name - …………………………………………………………………………………….…………..
Email Address - ………………………….………………………………………………………..…………..
Contact Tel Numbers – …………………………………………………………………………………………………
Institution - ………...………………………………………………………………………………….….
Supervisor Name (if applicable) - ……….……………………………………………………………………….…….
Collaborators (if applicable) - …….……………………………………………………………………………………….
I agree to the terms of data release and use specified on this form (see reverse): 
Signature of researcher making data request:
Name…………………….….…..…….Signed…………...………………………………..Date………..………

Purpose for request (e.g. Internal use only, Abstract or Publication, Conference presentation etc): …………………………………………………………………………………………………………..………
……………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………..……………………..

Title of proposed analysis: ………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………

Research question or hypothesis including objectives (200 words max): 
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………… continue on separate sheet if necessary.

Design/analysis (Include whether whole cohort, or a sub-set, and explain which sub-set):
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………

For all responses regarding information about variables, please refer to Fenland data dictionary (please contact the Senior Data Manager).

Outcome variable(s) (please use exact variable names):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..……… continue on separate sheet if necessary

Exposure variable(s) (Clarify main exposure, use the exact variable names):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. continue on separate sheet if necessary

Covariates requested (explain why – e.g., confounding factors, effect modifiers, mediators; use the exact variable names):
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..… continue on separate sheet if necessary

Please add any other information if appropriate
(e.g. any specific analytical issues. Max 150 Words):
……………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..… continue on separate sheet if necessary

Update Releases (e.g. if later releases are created do you require these?): 

Updates required:	Yes 	No 		If required up to:	(Mon) ____ / (Yr)____ 

When signed below by both the corresponding Studies Management Committee and the Senior Data Manager (or their delegates) this data release has been approved for use by the named researcher (or individuals directly under their control) to enable the analysis described above to be carried out and as such this document provides you with written rights to use this data for this analysis. Your signature on this form guarantees that you will maintain the data securely, limit access to it to those described above, will not make any copies of this data (other than for purposes of backup) or transfer via any portable device and that you will delete all copies of this information if requested by the MRC Epidemiology Unit. No other use of this information is permitted without first seeking further approval from the corresponding Studies Management Committee or the studies Chief Investigator or the Senior Data Manager. Any released information is confidential and should not be disclosed to any other parties under any circumstances without additional approval. No additional approval is necessarily guaranteed. Please quote the Unique Identifier for your release in all subsequent correspondence.

You must take all reasonable care to ensure the security of the data and maintenance of the conditions stated here by all people with whom this disclosed information is shared. A separate document containing the specific terms of the release will also be provided that describes more fully the full terms of data use.

For Office Use only: Date request received by:						 
 ADDITION Cambridge Management Committee: __ / __ / __

Approved for release:		Internal			External	

Not approved for release:			
Comments (if any):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Approval Signature (ADDITION Cambridge Management Committee):
Name…………………….……….…..…….Signed…………...…………………………………..Date…………..………

Data Manager (Name/Date) Comments (if any): 
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Master Set Title (assigned by DMT): ……………………………..………………..………..………..………...
Release Unique Identifier (assigned by DMT): …………………………..……………………..…………….
SDM Name………………………….…..…….Signed…………...……………………………..Date…………..………

Senior Data Manager to create PDF. PDF copy to DMT and to Clinical Research Manager. Paper copy to Study Coordinator