Name and Degree (if applicable)
Affiliation
Email Address
Briefly describe how you intend to use the CIQOL
Will you be using the CIQOL for research?
Yes
No
Will you be using the CIQOL for clinical practice?
Yes
No
Will you be using the CIQOL for teaching purposes?
Yes
No
Are you in training (undergraduate, graduate/medical student, resident, fellow)?
Yes
No
Do you intend to publish results with the CIQOL?
Yes
No
I agree to refrain from the following without written permission (initial):
Modifying or translating the CIQOL instruments
Reproducing and distribute the CIQOL instruments to other user
Integrating the CIQOL instruments into proprietary software
Using the CIQOL instrument for commercial/industry purposes
Items marked with an asterisk (*) are required.