PRO Licence Request Form

In order for Isis to prepare a study-specific copyright licence for the use of one of our PROs we require certain information from you/your organisation. We therefore ask that you complete the following licence request form. A representative of Isis Outcomes will contact you concerning your request.

Licence Request Form

The information you provide will be relied on and used by Isis for any licence agreement that may subsequently be issued to you. Please therefore ensure that it is complete and accurate. The information will be received and held in confidence and used by Isis solely for the purposes of the prospective licence agreement and interactions with you.

Please complete all the boxes unless otherwise indicated.

Licensee Details

Title of the registered legal entity wishing to acquire a licence

Type of organisation Please select Other organisation type not listed above

Full registered address of the organisation wishing to acquire the licence

VAT Number (optional) Required for EU-based organisations who are VAT registered.

How did you hear about us? (optional)

Contact at the organisation taking the licence

Title (Mr/Ms/Dr etc...)

First/Given name

Family name

Job title

Tel (inc codes)

Fax (inc codes)
(optional)

Email

Address (if different to registered address)

Study Details

All information will be received and held in confidence and used by Isis solely for the purposes of the prospective licence agreement and interactions with you.

Full title of the Study including any drug names and the purpose of obtaining the data from the Study Example: "Multicenter, randomized, double-blind, controlled pilot study to assess efficacy and safety of [DRUG NAME] as a therapy in the treatment of patients with [DISEASE]"

Study Protocol ID For example:
- NCT ID
- Grant number
- Company ID/Internal reference

Study Design (optional)

Phase of Clinical Trial (if any)
(optional)

Source of funding
(please complete if the Study is NOT being financed by the licensee) e.g. Commercial/Industry, publicly funded research, unfunded, private, other - please specifiy

Start date of Study

Completion date of Study

Number of patients to be assessed using the PRO

Number of separate completions of the PRO by each patient

Will the data from your Study be submitted to any regulatory body? (e.g. FDA/EMEA)

If yes, which body or bodies will you be submitting to?

Countries in which you plan to conduct the Study

Languages required for the countries you have requested
(optional) Please provide language requirements in the territories you have requested, e.g. English and French for Canada. Please refer to the web page for the PRO you wish to license for a list of the languages currently available