Have you already corresponded / talked with an HUI representative?
No (Skip to "Contact Information")
Wm (Bill) Furlong
Don't Know / Other (Please specify Who or Where):
(Room / Bldg
Courier address: Same as Mailing Address
Bldg / Street)
Principle Investigator: Same as 'contact person'
Number of Study Centres:
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Frequency of Assessment (eg. weekly, monthly, bi-annual, annually for ' x ' weeks, months, years...):
Recall period for assessment of health status
Mode of Administration (Check all that apply):
Language(s) in which HUI data will be collected:
Country(ies) in which HUI data will be collected:
Ages of subjects: Minimum(years)
Type of Study Population:
Data Collection Method (Check all that apply):
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')
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)
Your application will be sent by email to
the Research Coordinator at the HUInc Service Centre
Date Received:. HUI representative:
Date of Initial Reply: (YYYY-MM-DD)
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Letter to whom:
HUI package to whom:
Meeting with whom: , Where:
Date of Initial Meeting: (YYYY-MM-DD)