NAQC Research Request Application Form

NAQC makes annual survey data available to members through a peer-review process. Please complete the NAQC's Research Request Application Form and click here for information about the Data Request Protocol featuring:

research principles
data use prerequisites
the request protocol process
the request and review process
data use responsibilities and restrictions

First Name of NAQC Member and Lead Applicant *
Last Name of Name of NAQC Member and Lead Applicant: *
Professional Title *
Organization *
Email Address *
Phone *
Principal Investigator Name, Organization, Contact Information (if different from above) *
Name and Organization of all other members on Research Team and/or who will have access to NAQC data *
Title of Proposed Research *
Research Funding Sources *
Research Purpose and Objectives *
Research Questions *
How Research will be used (e.g., publish research article, develop new protocols, etc.) *
Analysis Plan (include a description of how each variable requested will help answer questions) *
Publication/Dissemination Opportunities *
Timing and format for how results of analyses will be shared with NAQC and its members *
Describe how data will be stored and secured *Include description of security measures, both physical and electronic, designed to ensure access to the data is limited to members of the research team.
Confidentiality of survey participants will be maintained in any publications or presentations *	Yes No
If No, provide an explanation. If appropriate, attach a letter of support.If appropriate, attach a letter of support for each quitline that has requested identification of itself in any presentations or publications.
Budget data will appear only as means, ranges or medians for “all states” and/or “all provinces” *	Yes No
If No, provide an explanation. If appropriate, attach a letter of support. If appropriate, attach a letter of support for each quitline that has requested identification of itself in any presentations or publications.
Letters of support
Supplemental materials (e.g., analysis plan)
Lead Applicant Digital Signature *

	Edit This Favorite
Name:
Category:
Share:	Yes No, Keep Private

Edit This Favorite