Eq-5D Registration Form

EQ-5D REGISTRATION FORM

Please complete this form and send it to [email protected] ALL FIELDS ARE REQUIRED – refer to page 3 for instructions

ABOUT YOU Job Title: Mr. Ms. Dr. First Name: Work environment: Last Name: University: Student Organization: University: Staff Postal address: Hospital / clinical practice City: Government / Non-profit / HTA agency Postal code: Health Insurance Province: ALBERTA Country: CANADA Consulting / CRO / vendor Industry / Pharmaceutical / Medical Device Email: Health Care Communications Phone: Other; please specify: INTENDED USE OF EQ-5D EQ-5D will be used for: Research (intend to publish the results) Internal use (clinical use, routine data collection, etc…) Other; please specify:

Title of your study or project: Objective(s):

Source of funding/sponsor: Study Design/primary use: Intervention study (randomized or non-randomized) Observational (e.g., case-control, cohort and cross-sectional studies) Methodological study Registry Routine data collection

1 Other; If other, specify:

Clinical area: Number of patients / respondents: Start date (year only): End date (year only): EQ-5D VERSION, MODE OF ADMINISTRATION AND LANGUAGES You like to use (check all that apply): EQ-5D-3L EQ-5D-5L EQ-5D-Y

Mode of administration (check all that apply): Self complete – paper Self complete – Digital (Tablet) Self complete – Digital (Web) Self complete – Digital (PDA) Self complete – REDCap (Web) Self complete – REDCap (Tablet) Proxy 1 – Paper Proxy 2 – Paper Proxy 1 – Digital (Tablet) Telephone – Paper Face to Face – Paper

Language(s) (check all that apply): English French Other: specify:

WRAPPING UP As part of your study, are you planning to modify the EQ-5D? Yes No

Are you prepared to have this information published in EuroQol reports regarding usage of the EQ-5D? Note that only anonymized information will be published Yes No

Can we contact you by email in case of important product notifications? Note that you can always opt-out/ ask to be

2 removed from the mailing list Yes No

Do you give APERSU permission to publish your project information (title and design of project, organization undertaking the project) on its website to form a registry of EQ-5D projects in Alberta? Yes No

Do you agree with our Terms of Use*? Yes No

*Terms of use: Please note that without the prior written consent of APERSU and the EuroQol Office, you are not entitled to use, reproduce, alter, amend, convert, translate, publish or make available in whatever way (digital, hard-copy etc) the EQ-5D and related proprietary materials.

3 Brief instructions for completing the registration form:

Title: Specify the title of your study/project. Try to be as specific as possible as the title will appear in the license.

Objectives(s): A brief statement about the objective(s) of your project. Please note that if EQ- 5D use for routine data collection, the objective could be described as: “To measure and monitor the health status of [insert population] in [insert setting]”.

Source of funding: Indicate source of funding for your project. If this is part of practice in your setting, state “internal funding”. If there is no funding for your project, state “not applicable”.

Design: Choose the design from the list, or list other designs if applicable. Note that using the EQ-5D in routine clinical practice is considered “routine data collection”.

Clinical area: Indicate clinical area whether EQ-5D will be used. Could be general e.g., primary care, hospital setting, or specific to a disease population e.g. diabetes, or age group e.g. elderly.

Number of patients: Please indicate an approximate number of patients/respondents who will complete the EQ-5D. If the application is for routine data collection, indicate an approximate maximum number of respondents per year.

Start date: Indicate the start date (year only) of your use.

End date: Indicate the end date (year only) of your application. If end date is unknown, indicate an approximate finishing date. If the use is for routine data collection, set the end-date for 3 years from the start date as the EQ-5D license will be issued for 3 years, and the end-user has to renew it every 3 years if you plan to continue to use it.

EQ-5D versions: For full description of the EQ-5D versions and modes of administration, please refer to the information on our website www.apersu.ca under “About EQ-5D”. More detailed information is available on the EuroQol website www.euroqol.org

Modifying EQ-5D: Any change in the content, order or format of the EQ-5D questions (dimension and visual analogue scale) is considered a modification.

If you have any questions, contact us at [email protected]