| 1) |
Name: _____________________________________________________________________
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| 2) |
Institutional Affiliation: ________________________________________________________
|
| 3) |
Project Title: ________________________________________________________________
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| 4) |
Phone Number:__________________________
Fax Number:_________________________
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| 5) |
E-mail Address: _____________________________________________________________
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| 6) |
Mailing Address: _____________________________________________________________
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| 7) |
Is your project related to a dissertation or other degree requirement?
_________________
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| 8) |
List the source(s) of funding (if any) for the project.
___________________________________________________________________________
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| 9) |
I have read the information on the AHRQ Data Center
provided on the MEPS Web site and understand that microdata used in
the analysis
will not be released, and that release of summary data (tables, parameter
estimates) is dependent on
a confidentiality review.
Yes ________ No ________
|
| 10) |
List below the MEPS data file(s) you are requesting access to (i.e.,
1996 HC-IC file, MPC ). Please include any PUF files you may need
access to.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
|
| 11) |
List below any MEPS-HC variables by instrument section and question
number that are not available for public use which you are requesting
access to.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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| 12) |
If you have data that you want to merge with AHRQ data describe
how and why the merge is to be done in your research summary (item
#17), and below describe the content of the data to be merged. Also,
attach documentation for each file to be merged, including file layout,
number of records, variable names and descriptive variable labels.
Data will not be merged unless the documentation is complete, including
variable labels and value labels. The merging of files requiring the
use of identifying or potentially identifying data will be conducted
by our contractor. Complex merges may require the researcher to enter
into a task order agreement with the data processing contractor. A
cost estimate will be provided once the application is approved. If
merging State level data, there must be data for each State, and State
identifiers will be removed or encrypted after the merge is complete.
The resulting data set will be considered restricted and its use limited
to the AHRQ Data Center.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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| 13) |
Please provide an estimated time frame for completing your Data
Center project and how often you would like to have access to the
Data Center, and with what frequency (daily for two weeks, weekly
for two months, etc). Please be aware that it can take four to six
weeks after your project has been approved to have your data files
made available to you in the Data Center.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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| 14) |
Please list your publication plans or other anticipated uses of
the data/research
results.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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| 15) |
List below the persons other than yourself that will be working on this project
who may access the Data Center.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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| 16) |
List below the software that you need access to in the Data Center:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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| 17) |
Attach the following items: - Cover letter addressed to the Manager of the AHRQ Data Center.
- Resume or Curriculum Vitae for all persons associated with the
project that will access the Data Center.
- For students, a letter from the department chair confirming
your student status and that the project is related to a degree
requirement.
- Abstract of the proposed research, not to exceed two pages.
- Summary of the proposed research, including a description of
why publicly available data are inadequate. The summary should
include the kind of output you want to remove from the Data Center.
On what page of the summary is this output specified?
- Notice of IRB review.
- If merging data, a letter from the data sponsor giving the AHRQ
Data Center permission to keep the data and to make it available
to other Data Center users.
|
I assert that the above and attached
information is, to the best of my knowledge, true and complete.
Name (print/type): _____________________________________________________
Date: _______________________________ |
540 Gaither Road Rockville, MD 20850