TAVI Steering Group Data Application Form

  1. PRINCIPAL INVESTIGATOR

Title, forename, surname: / .
Employing organisation: / .
Position in organisation: / .
Address of organisation: / .
.
.
Telephone: / .
Email: / .

Please attach the Principal Investigator’s Curriculum Vitae.

2. RESEARCH TEAM / CO-APPLICANTS

Details of each Research team member involved in the proposed project.

Research team members / Co-applicants / Employing organisation / Position in organisation / Contact details (Email address/Telephone no)

3. PUBLICATIONS OF THE RESEARCH TEAM MEMBERS

List of the main publications of each Research team member involved in the project.

4. PREVIOUS APPLICATIONS

Have you or any of the Research team members/co-applicants applied for TAVI data

in the past?

If Yes, please give details:

Main Applicant / Application Date / Project Title / Scientific Outputs

5. FUNDING

Do you already have funding to carry out this project

If you are planning to seek funding to carry out this project and the grant application is to be partially or totally based on the use of TAVI data, please give details about the funding application.

Name of funding body
Dates
Applicants
Title of application
Synopsis of application (max 100 words)

6. RESEARCH PROJECT

6.1 PROJECT TITLE
6.2 SUMMARY
A brief summary of up to 200 words describing the aims of the study/research project
6.3 CONTEXT
Where research is part of a larger programme, please give details.
6.4 PROJECT DESCRIPTION
Full description of the purpose/s for which the data are requested (maximum 4 A4 sides excluding references)
Background
Scientific hypothesis
Objectives
Methodology and planned statistical analyses
Competing interests
References (max 10)
6.5 PLANNED SCIENTIFIC OUTPUTS
Intended outputs/publications arising from the use of these data, including abstracts, posters and research papers.

7. DATA REQUESTED

Data items required for analysis. Please refer to the TAVI dataset and define the time period. Please be as specific and detailed as possible when compiling this list.

TAVI Steering Group Data User’s Agreement

To be signed when the application has been approved

Title, forename, surname: / .
Work Address: / .
.
.
Telephone: / .
Email: / .
Project title: / .

I agree that my project will use the requested TAVI data and will be conducted according to the terms specified in the TAVI Steering Group Data Sharing Policy.

I accept that my access to the TAVI data is limited only to what is relevant for completion of the above named project.

I accept that if I knowingly disregard the conditions relating to the release of data given in theTAVI Steering Group Data Sharing Policy this will be considered a serious offence and will result in action being taken against me and my organisation.

I confirm that I have read this document and agree to abide by the terms and conditions outlined within.

Signature of data user: / .
Name in block capitals: / .
Date: / .
Signature of research members (and everyone having access to the data- see data sharing agreement) / Names in block capitals / Date
.
.
. / .
.
. / .
.
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Signature of TAVI Collaborator:
Name in block capitals: / .
Date: / .
Signature of TAVI Data Monitoring Group Chairman: / .
Name in block capitals: / .
Date: / .

Checklist for applicants

Download the TAVI datasetfrom the BCIS web pages to determine which data items are available.

Download the TAVI Steering Group Data Sharing Policy to understand what is required for your submission.

Make informal contact with TAVI Data Monitoring Group chair to discuss feasibility of your project.

DownloadtheTAVI Steering GroupData Application Form from the BCIS web pages.

Complete all sections of the TAVI Steering Group Data Application Formand return to the TAVI Data Monitoring Group chair with copies of your

organisation’s System Level Security Policy

project’s LREC/MREC approval or equivalent

After approval of your application in principle by the TAVI Steering Group

Complete, sign and return the TAVI Steering Group Data User’s Agreement to the TAVI Data Monitoring Group chair

Confirm safe receipt of data

Please return your completed form to:

Dr Peter Ludman, DMAG Chair

Department of Cardiology
Queen Elizabeth Hospital
Edgbaston
Birmingham

B15 2TH