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Preliminary Identification Form

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All fields are mandatory

1. LEAD RESEARCHER INFORMATION

(The Lead Researcher is the person responsible for day-to-day oversight, conduct and management of the proposed research analysis).

Name (title, first name, middle initial, last name):

Current position

Institution and department

Address

City

State/Province

Post/Zip Code

Country

Telephone

Email address

Questa email non può essere utilizzata per la richiesta

2. RESEARCH PROPOSAL AND CHIESI CLINICAL TRIAL DATA REQUESTED

Why you would like to access Chiesi Farmaceutici S.p.A. clinical trial data (Limit to. 500 words)

Please specify the clinical trial you would like access to by referring to the ClinicalTrials.gov Identifier or the EudraCT Number or the Study ID (if multiple trials, list all)

Which clinical data you would like to request access and why (Clinical Protocol, Patient-level Data, Study-level Data, full Clinical Study Report) (Limit to. 500 words)

3. PRIVACY NOTICE

Privacy Notice PDF

I have read and understood the Privacy Notice and I consent to the processing of my personal data and information as described therein.

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