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 / WWW
c)	Mark scanning/Sense sheet
d)	FAX
e)	Telephone Interview
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 1^st 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 Research Coordinator at the HUInc Service Centre
via (huinfo@healthutilities.com)

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Date Received:.  HUI representative:
Date of Initial Reply: (YYYY-MM-DD)

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