HUInc Health-Related Quality of Life Research Application Form
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HUInc Health-Related Quality of Life Research

Please complete the entire form.
The information is vital to assist HUInc service personnel
in assessing your needs and recommending the appropriate
HUI instrument for your study.

Have you already talked with an HUI representative? No (Skip to "How did you learn of the HUI")
Wm (Bill) Furlong
Mary Gauld
John Horsman
David Feeny
George Torrance
Don't Know / Other (Please specify Who or Where):

How did you learn about the HUI?
a) Used HUI previously; 
b) Recommended by colleague; 
c) Conference - HUI Booth; 
d) Literature search; 
e) Referenced in literature; 
f) On-line (google) search; 
g) Saw print advertisement; 
h) Other (please specify):

Contact Information

Name (Required):

Mailing address:
(Company name)
(Room / Bldg / Street)
(Country),(Postal Code)

Courier address: Same as Mailing Address  or...
(Company name)
(Room / Bldg / Street)
(Country),(Postal Code)

Email (Required):

Principle Investigator: Same as 'contact person'  or...
PI Name:

Study Information

Title of Study:

Study Design:
a) RCT (randomized controlled trial) 
b) Cohort study; 
c) Cross sectional survey; 
d) Clinical series; 
e) Other (Specify):

Number of Study Centres: Single Centre.  Multi-Centre (Specify # of centres) .

Frequency of Assessment (eg. weekly, monthly, bi-annual, annually for ' x ' weeks, months, years...):

Recall period for assessment of health status
a) Usual (eg. "...describe 'usual' ability to ___ ..."
b) One-week (eg. "...describe ability, during the past week, to ___ ..."
c) Two-week (eg. "...describe ability, during the past 2 weeks, to ___ ..."
d) Four-week (eg. "...describe ability, during the past 4 weeks, to ___ ..."
e) Other Recall period (Specify):  

Assessment Viewpoint:
a) Self-assessed (Subject will answer for him or herself
b) Proxy-assessed (Someone else, parent, physician, ..., will answer on behalf of the subject)
(Specify relationship of proxy to subject):  

Mode of Administration (Check all that apply):
a) Interviewer administered, by phone 
b) Interviewer administered, face-to-face 
c) Self administered
d) 'Other' Administration (Specify):  

Language(s) in which HUI data will be collected:

Country(ies) in which HUI data will be collected:

Ages of subjects: Minimum(years)        Maximum(years).

Type of Study Population:
a) Clinical (Specify disease/condition): 
b) General population
c) Other (Specify): 

Data Collection Method (Check all that apply):
a) Paper
b) Computer
c) Mark scanning/Sense sheet
d) FAX
e) Over the phone
f) Other (Specify): 

Expected start date of data collection:(YYYY-MM-DD...Example:2000-06-11)

Study Duration. How long do you expect the study to last?
          (Time from 1st subject 'in' until last subject 'out')
a) 6 months
b) 1 year
c) 2 years
d) 5 years
e) Other (Specify): 

Expected end date of data collection:(YYYY-MM-DD...Example:2003-09-04)

Comments or other information about the study that might be useful to the HUI Service Centre...

Have you used or been associated with another project that has used HUI instruments?
  No .   Yes - Please give details (Optional, but will help keep our archives/bibliography/reference lists current)
(Eg. Year, Project/Study name, Principal Investigators, Publications, or other information...)

Date of submission:(YYYY-MM-DD...Example:2000-03-24)

Thank you.
Your application will be sent by email to the
Operations Manager at the HUInc Service Centre.

HUInc. Leader in Health-Related Quality of Life ResearchReturn to HUI home page.
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Date Received:HUI representative:
Date of Initial Reply: (YYYY-MM-DD)

Reply by ...

Email to address:

Letter to whom:

Phone number:

Fax number:

HUI package
HUI package to whom:

Meeting with whom: , Where:

Date of Initial Meeting: (YYYY-MM-DD)

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