Simon's Heart Screening

Data Request Form for Researchers

Primary Investigator Information

Date of Application

Institution

Lead Investigator Credentials (MD, PhD, etc)

Lead Investigator Title (assistant professor, etc)

Lead Investigator Department

Office Phone

Is this a student project?

Yes

Mentor's Name

Mentor's Institution

Mentor's Title

Mentor's Email

Mentor's Office Phone Number

Proposal Information

Purpose of Your Request

Peer-Reviewed Manuscript

Dissertation

Are you a student in an accredited Doctoral, Medical, or Master's program?

Yes

IRB Application

Is the project funded?

Yes

Is funding for the project under review?

Yes

Funding Agency

Grant number or name

Collaborators

	Name	Title	Institution	Role
1

Project Information

Project Title

Scientific Abstract (250 words)

Lay Abstract (200 words)

Background (500 words)

Proposed Research Methods (500 words)

Requested Data

Registration and History

Vitals

Heart Murmur Tests

Electrocardiogram Results

Echocardiogram Results

I, , hereby certify to the best of my knowledge that the information provided in this document is accurate, truthful and verify that all collaborators have current human subjects’ protections training on this day of , in the year of .