Aphasia Data Contribution Form
Data for the RELEASE Project can be contributed using this form; please complete all applicable sections and attach all available datasets and documentation.
Section 1 Clinical Dataset Information1.1Using the checklist below, please indicate that the following items exist and are valid for your dataset.
By checking the boxes it is understood that you give permission on behalf of your group to share these data for the purpose of anonymised, secondary data analyses.
Documented Entry Criteria
Documented consent or waiver of consent following local Ethical Committee approval, for the primary dataset
Diagnosis of Stroke
Documented time since stroke
Baseline assessment of aphasia severity
A minimum dataset of 10 individual patients with aphasia as a consequence of stroke
Please check the boxes corresponding to the format of your data.
Microsoft Excel spreadsheets
Microsoft Access Database
SAS data sets
Other (please state)
Section 2.0 Gatekeeper Approval for Contribution
Please provide contact details for the Investigator who will represent the study, and who grants permission for the dataset to be shared for the purposes of the RELEASE project (gatekeeper).
Investigator Phone Number
Investigator Email Address
All fields marked with * are essential
Name of Study - Please tick all that will be mailed seperately
Annotated Sample Data Collection Sheet*
Protocol or detailed project description*
Original Ethics Approval*
Final report/ Publication(s) reporting study findings, if applicable*
I hereby grant permission for the contribution of aphasia data
Terms & Conditions
I Agree to Terms and Conditions
Attached ZIP file containing all required documents
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