TEST Data Use Form This form is used to request permission for data use from PCG studies. Note: Teleconferences to discuss your request with PCG staff are welcome and encouraged. Requester informationRequester name:*Though more than one person may be involved with a project, only one person is permitted on the request. The investigators are responsible for abiding by PCG policies for this request.Requester email address:* Date of request:* MM DD YYYY Project InformationPCG study for which you are requesting data permission? (e.g. REG001-09):*Do you wish to use all PCG data or specific institutions?* All institutions Specific institutions List Specific Institutions:Brief overview of the project:*PCG Electronic DatabaseAll data collected on the PCG case report forms will be included unless otherwise specified. For example, if you wish to receive follow up data only, please indicate this below:Please note that for DICOM-RT files, the data that is included is from July 2017 to current. Requests for DICOM-RT data prior to this date will be considered a special project with a timeline of a minimum of 90 days. PCG is not able to guarantee all files can be obtained from the institutions.If medical records may be needed for your project, please contact PCG directly at [email protected] or call the office at (630) 836-8668. Further information will be provided.Goal of the projectIf abstract, where would you like to present it?Conferences/LocationsYearThe year the abstract will be presentedIf manuscript, what journal(s) would you like to target?Other goal for your projectSignatureConsent* I verify that I have read and agree to abide by the current PCG Data Use and Publication Policy.CommentsThis field is for validation purposes and should be left unchanged.