User Profile

Name: *

Title/Position: *

Company/Organization: *

Street: *

example

City: *

Province/State: *

Postal Code/Zip: *

E-mail: *

Telephone: *

Fax: *

Number of years your organization has been in business: *

Note: YOU MUST ANSWER ALL QUESTIONS BELOW.
If you believe that a question is not applicable to your request, please fill in “N/A” in the response area.

1. A. please explain how you intend to use the dash and/or quickdash outcome measures. : *

1. B. please provide details of the product and/or service you are providing (if different from 1A). By service we mean activities related to your clinical practice, research, evaluation, training, etc.: *

Select all that apply.

3. What is the cost structure for the product and/or service you are providing (e.g., per unit cost)?: *

4. What is your estimated and target volume per year?: *

5. How long are you requesting to use the dash and/or quickdash outcome measures?: *

6. Please list other outcome measurement instruments that will be included in the product and/or service you are providing. : *

E.g. Sf-36, Spadi, Brigham, eq5d, etc.