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Step 1 of 5 - Primary Investigator (End User) Info
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Primary Investigator's Contact Info
As the "End User" requesting use of the ASK
@
, please complete the following:
Salutation
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Name
*
First
Last
Your Position
*
Your Institution
*
Please indicate the institution with which you are currently employed.
Work Email
*
Work Address
*
Street Address
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Work Phone
*
(If outside North America, include your country code)
Fax
Project Coordinator's Contact Info
Please enter the full contact information of the project coordinator's contact (if any).
Project Coordinator Contact
I am the project coordinator contact for this request.
Select this option if you are the "Project Coordinator" contact related to this ASK license request.
Salutation
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Name
*
First
Last
Position
*
Institution
*
The alternate contact person's institution.
Email
*
The alternate person's email address.
Work Address
*
Street Address
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Work Phone
*
(if applicable, include an extension)
Fax
Summary of the Research Project
Project Title
*
Project Description
*
Characteristics of the Population being assessed:
(e.g., describe the clinical conditions)
Primary Outcome
*
ASK
Other
Other outcome:
*
Type of research:
Clinical Trial
Clinical Practice
Comparative Study
Cross-sectional
Descriptive Study
Longitudinal Follow-up
Total number of expected subjects:
*
Number of times the ASK will be used (per subject):
*
Please enter a value greater than or equal to
1
.
Length of subject follow-up:
(in months)
Start Date
*
End Date
*
"End Date" must be less than 1 year from "Start Date"
List any other questionnaires used in your project:
Versions of the ASK required
*
Performance
Capability
Project Financing
Academic research:
*
Funding Approved
Funding Pending
Unfunded
Granting Agency / Financial Sponsor (if any):
*
Alternate Language Versions
Canadian English is the default, however alternate language versions are available upon request.
The ASK is provided in its original language: Canadian English. The Canadian English version of the ASK has been validated. However, there are currently: (1) Canadian French, (2) US Spanish, (3) UK English, and (4) Dutch versions of the ASK available upon request. To request a version (other than Canadian English), send an email to Dr. Nancy Young at
activitiesscaleforkids@laurentian.ca
The use of the ASK is subject to the following conditions:
This user agreement is for the use of the ASK© data collection forms, with all rights reserved to Dr. Nancy L. Young, author of the ASK©.
Fee: the use of the ASK© questionnaire and related materials by undergraduate and graduate students that are not part of a larger funded academic research project is free of charge. The use of the ASK© and related materials for any non-funded academic research, funded academic research, large non commercial organization research and evaluation (e.g., States, Nations, Hospitals, Healthcare Systems) or commercial purpose and large non-commercial organization annual unlimited research/evaluation/clinical use is subject to a royalty fee payable to the author, Dr. Nancy L. Young, and will be used to support ongoing development research on the ASK©.
"User" shall not modify, abridge, condense, translate, adapt, recast or transform the ASK© in any manner or form, including but not limited to any minor or significant change in wordings or organization without the prior written consent of Dr. Nancy L. Young.
"User" shall not reproduce the ASK© except for the limited purpose of generating sufficient copies for use in the abovementioned clinical investigations and shall in no event distribute copies of the ASK© to third parties by sale, rental, lease, lending, or any other means.
In case of publication, user shall cite Young NL, Williams JI, Yoshida KK, and Wright JG. Measurement properties of the Activities Scale for Kids.
Journal of Clinical Epidemiology
, 2000. 53(2): p. 125-137 in the reference section of the publication. Optional references that may also be included are: Young NL, Williams JI, Yoshida KK, Bombardier C, and Wright JG. The context of measuring disability. Does it matter whether capability or performance is measured?
Journal of Clinical Epidemiology
, 1996. 49(10): p. 1097-1101 and Young NL, Yoshida KK, Williams JI, Bombardier C, and Wright JG. The role of children in reporting their physical disability.
Archives of Physical Medicine and Rehabilitation
, 1995. 76(10): p. 913-918. It is requested that a copy of all published papers and abstracts using the ASK© be provided to Dr. Nancy L. Young.
All data, results and reports obtained by, or prepared in connection with, the authorized use of the ASK© shall remain the "User's" property. However in the interest of furthering the usefulness and development of the ASK©, User agrees to share data, results and reports obtained through use of the ASK© with the author, Dr Nancy L. Young, subject to the removal of confidential and patient identifying information.
All and any information related to the ASK© including but not limited to the following: information concerning clinical investigations, creations, systems, materials, software, data and know-how, translations, improvements ideas, specifications, documents, records, notebooks, drawings, and any repositories or representation of such information, whether oral or in writing or software stored, are herein referred to as confidential information. In consideration of the disclosure of any such confidential information to the other, each party agrees to hold such confidential information in confidence and not divulge it, in whole or in part, to any third party except for the purpose specified in this agreement.
If, at any time during the term of this agreement, either party hereto learns of any infringement by a third party of any Intellectual Property Rights in connection with any of the ASK©, the party first learning of such infringement shall promptly notify the other.
This agreement holds for the above mentioned study only. The use of the ASK© in any additional study of the "User" will require a separate agreement.
Under no circumstances may Dr. Nancy L. Young or Laurentian University be held liable for direct or consequential damage resulting from the use of the ASK©.
This agreement shall be effective as the date set forth in the preamble and shall continue for a term of a maximum of 5 years. Either party may terminate this Agreement immediately upon providing written notice to the other party in the event of (a) the other party's unexcused failure to fulfill any of its material obligations under this Agreement or (b) upon the insolvency or bankruptcy of, or the filing of a petition in bankruptcy or similar arrangement by the other party. Upon termination, "User" shall cease all use of the services of the ASK©. Following the execution of this agreement, the User will be redirected to a webpage containing the agreed upon material for download. Upon expiration or termination of this Agreement Dr. Young may retain possession of confidential information it acquired under this agreement.
The entire agreement between the parties hereto is contained herein and this Agreement cancels and supersedes all prior agreements, oral or written, between the parties hereto with the respect to the subject matter hereto. This Agreement or any of its terms may not be changed or amended except in writing and the failure by either party hereto to enforce any or all of the provision(s) of this Agreement shall not be deemed a waiver or an amendment of the same and shall not prevent future enforcement thereof. If any one or more of the provisions or clauses of this Agreement are adjudged by a court to be invalid or unenforceable, this shall in no way prejudice or affect the binding nature of this Agreement as a whole, or the validity or enforceability of each/and every other provision of this Agreement.
This agreement may not be altered, amended or modified except by written document signed by all parties.
Yes, I have read and agree to the term and conditions of this agreement.
*
Yes, I agree.
This agreement is between Nancy Young at Laurentian University and ("User")
*
First
Last
Institution
*
Today's Date
*
Comments
Enter your comments above. If you have QUESTIONS, email Dr. Nancy Young at
nyoung@laurentian.ca
ASK License Fee
ASK License: Non-Funded Academic Research/Clinic Practice Evaluation
*
Price:
$ 250.00 CAD
Note: You'll be able to select a payment method later, once you submit the registration form.
ASK © License
for
Non-Funded Academic Research
License Fee:
$250 CAD / year