CORE Information Request

1. Title(*)
   Mr.Mrs.Ms.MissDr.Prof.Assoc/Prof.Clin/Prof.Please select your desired title
2. 
   Please provide your full name(*)
   Please provide your name for our records
3. 
   Please provide your organisation name and postal address(*)
   Please complete organisation information
4. 
   Please provide your position title(*)
   Position title
5. 
   Please provide your email address(*)
   Please provide a valid email
6. 
   Please provide your phone number including area code and international dialing code if outside Australia
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7. 
   Please provide your mobile phone
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8. 
   Please provide your fax number
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9. 
   Are you a financial ANZCIS Member?(*)
   YesNoPlease select 'Yes' or 'No'
10. 
    Are you a non-ANZICS Member associated with a current contributing ICU(*)
    YesNoPlease select 'yes' or 'no'
11. 
    If you selected 'Yes' above, then please provide the name of your unit
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12. 
    Why would you like this information(*)
    Research Purposes
    Mailing List
    Seminar/Meeting Promotion (please specify below)
    Advertising/Product Promotion(please upload any product packs at the end of this form)
    Other (please specify below)
    Please select at least one of the above
13. Please provide any additional information
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14. 
    From which registry/registries would you like this information?(*)
    Australian New Zealand Paediatric Intensive Care Registry (ANZPIC)
    Adult Patient Database (APD)
    Critical Care Resources Registry (CCR)
    Please select at least one
15. 
    Specifically what information do you require from ANZICS CORE? Please provide as much detail as possible
    Any supporting documentation may be submitted at the end of this form(*)
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16. 
    Please explain exactly how this information will be used
    Any supporting documentation may be submitted at the end of this form(*)
    Please provide information
17. 
    Will this data be used in a publication (including manuscripts, abstracts)?(*)
    YesNoPlease select 'Yes' or 'No'
18. 
    Will this data be used in a presentation (including conference or education)?(*)
    YesNoPlease select 'Yes' or 'No'
19. 
    Please upload any supporting files, information or documentation pertinent to this request
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20. TERMS AND CONDITIONS

    I understand that Government Health Departments, Health Professionals and ANZICS members seeking information for research purposes will receive one hour free, with each hour thereafter billed at $250 (plus GST) per hour. (Health Professionals in this context are defined as Doctors or Nurses working in hospitals, conducting research). I understand that all other requests will be billed at AUD$250.00 per hour (plus GST).

    I understand that all fees are charged at the discretion of ANZICS CORE. I understand that where fees are charged, costs are based on resources and time required to process requests. I understand that an estimate of cost and any variations will be given in writing based on the consultancy fees stated above. I understand that all fees and charges are payable prior to processing of requests and a tax invoice will be issued.

    I undertake that I will use this data only for the reasons stated in the application above and will not extend the analysis beyond the purposes outlined in the application without prior consent of ANZICS CORE. I will not provide this data to any persons nor other parties (including hospital, government, commercial bodies) unless expressly detailed in the above application. I will appropriately acknowledge the involvement of CORE regarding the data provided. I confirm that I have read the terms and conditions of the ANZICS CORE Publication Policy and agree to follow them as outlined.

    If you intend to publish work based on the data provided by ANZICS CORE:

    • You must complete, agree to and return the ANZICS CORE Publication Policy download here (534.5 kB) in order for your request to proceed. ANZICS CORE must be noted as a co-author as per the Publication Policy. This includes (but is not limited to) manuscripts, abstracts and presentations.
    • Prior to submitting for publication, the work must be reviewed by the ANZICS CORE Management Committee or Paediatric Study Group.
    • Ethics committee approval is required for all intended scientific publications in peer reviewed journals. This should be sought by the primary author or person in charge of the project from their local institution. Further information is provided in the Publication Policy.

    (*)
    Agree (Please indicate that you have read and accepted the terms and conditions by ticking the box 'Agree')

    
    Please select 'Agree' once your have read the conditions.
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    Please complete all required fields