**AGRICULTURAL HEALTH STUDY**

**REQUEST FORM**

Type of Request:

\[ \] Data Request (complete sections A, B, and C)

\[ \] Collaboration Request (complete sections A and B)

######## Section A

  --------------- -- --------- ---- -- ----------- ------- --- -- ---------------- -- ------------ --------
  Name of                                                                             Date of      
  Requester:                                                                          Request:     

  Date Needed                                                                                      
  (allow time for                                                                                  
  approval                                                                                         
  signatures and                                                                                   
  data                                                                                             
  processing):                                                                                     

  Phone Number of                                                                                  
  Requester:                                                                                       

  E-Mail Address:                                                                                  

  Tentative                                                                                        
  Manuscript                                                                                       
  Title:                                                                                           

                                                                                                   

  Proposed                                                                                         
  Journal Article                                                                                  
  will be                                                                                          
  submitted to:                                                                                    

  Lead                                                                                             
  Investigator:                                                                                    

                     (First                                       (Institutional                   
                     Author)                                      Affiliation)                     
  --------------- -- --------- ---- -- ----------- ------- --- -- ---------------- -- ------------ --------

Collaborators: (Secondary Authors)

  --------------------------------- -- ----------------------------------
  Name (Print)                         Initials/Signature

                                       

                                       

                                       

                                       

                                       

                                       

                                       

                                       

                                       

                                       
  --------------------------------- -- ----------------------------------

  ------------------------ ------------ ------------------ ----------- --------
  For Coordinating Center  Request No.                                 
  Use Only                                                             

                           Date data                       Initials:   
                           sent:                                       

                                                                       
  ------------------------ ------------ ------------------ ----------- --------

**[Section B]{.underline}**

Brief Narrative Description of Proposed Research:

  -----------------------------------------------------------------------
  Purpose:

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  Methods:

  -----------------------------------------------------------------------

**[Section C]{.underline}**

Specific Data Items Requested

Phase I

\[ \] Private Applicator File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Commercial Applicator File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Spouse File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Female and Family Health File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Other (specify data set)

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

Phase II

\[ \] Private Applicator File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Commercial Applicator File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Spouse File

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

\[ \] Other Files (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -------------- --------------------------------------------------------
  Selection      
  Criteria:      

                 

                 

                 
  -------------- --------------------------------------------------------

  -------------------- ------ ---------------------- ---------------------
  No. of variables            File containing        
  requested:                  variable list\*:       

  -------------------- ------ ---------------------- ---------------------

Output format:

  ---------- ------------------------------------------------------------
  \[ \]      SAS (preferred-specify PC or Unix)

  \[ \]      Comma Delimited

  \[ \]      ASCII Column Delimited
  ---------- ------------------------------------------------------------

Format in which data is to be sent:

  ------ ----------------------------------------------------------------
  \[ \]  Diskette/CD-ROM

  \[ \]  Paper copy (if output is less than 60 pages)

  \[ \]  Internet (Secure FTP only)
  ------ ----------------------------------------------------------------

######## *You may complete and return the remainder of the Request Form by email, but we must receive the signed Pledge of Confidentiality by fax. Please fax the signed Pledge of Confidentiality to Ben Laimon at 301.294.2085. Be sure to include your printed name and the title of the project.* 

######## Pledge of Confidentiality for Collaborators

Prior to receiving AHS data it is required that collaborators review and
sign the following pledge of confidentiality.

I hereby certify that I will keep completely confidential all
information arising from Agricultural Health Study data concerning
individual respondents to which I gain access*.* I also certify that I
will abide by all requirements of the NCI Institutional Review Board
(IRB) and other applicable IRBs. Beyond the research team, I will not
discuss, disclose, disseminate, or provide access to survey data and
identifiers except as authorized in writing by the Agricultural Health
Study Executive Committee. I shall use the Agricultural Health Study
data only for approved purposes. I am also aware that I am responsible
for the compliance of all other personnel under my supervision who have
access to the data provided to me by the AHS. I agree to report any
breaches in confidentiality to the Executive Committee within 24 hours
of their being discovered. I give my personal pledge that I shall abide
by this assurance of confidentiality.

Name (Signature)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (Print)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Project Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Mailing Address (This should be a street address so that Federal
Express will deliver to it):**

Address
1\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address
2\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Zip\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######## 

######## 

########  

######## Section D

Approval:

  -- ------------------------------------ ------- ---------------------- ---
                                          Date:                          

     Michael C. R. Alavanja, Dr. P.H.,                                   
     Project Officer                                                     

                                          Date:                          

     Laura Beane-Freeman, Ph.D.                                          

                                          Date:                          

     Dale P. Sandler, Ph.D.                                              

                                          Date:                          

     Jane Hoppin, Sc.D.                                                  

                                          Date:                          

     Kent Thomas                                                         
  -- ------------------------------------ ------- ---------------------- ---