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Applicant Information

Application for Use of South Carolina Alzheimer’s Disease Registry Data

Office for the Study of Aging
Arnold School of Public Health
University of South Carolina
Columbia, SC 29208

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Name of Requestor
Job Title
Organization
Department
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Address
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Phone Number
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Email Address
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Brief description of the project or study
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Describe the data elements needed
Time frame for requested data. Beginning Date
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Time frame for requested data. Ending Date
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Requested delivery method (Please choose one)
Requested data format (Please choose one)