SAMPLE. RISE Data Use Request Form - Academic. Step 1 - Contact Information. Who will serve as the point of contact for this project?

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1 Page 1 Step 1 - Contact Information Who will serve as the point of contact for this project? 1. *First Name: Middle Initial: *Last Name: Suffix: (e.g. Jr., III) Degree(s): (e.g. MD, PhD) *Institution/Organization: * Address: *Phone Number: (Format: XXX-XXX-XXXX) Extension: 10. Street Address: 11. City: 12. State: Select: 13. Zip Code:

2 Page 2 Step 2 - Author(s) 14. *Principal Investigator: (Provide first name, last name and degrees) *Is the PI affiliated with an academic institution, not-for-profit organization or governmental agency OR employed at a private practice? *PI's Institution/Organization: *Is the PI an ACR/ARHP member? Select file to upload... Allowed file type(s):.doc,.docx,.pdf *Upload the Principal Investigator's ACR Disclosure Form: Select file to upload... Allowed file type(s):.doc,.docx,.pdf What is his/her member ID number? *Upload the Principal Investigator's NIH biosketch or CV: Collaborator(s): First Name Last Name Degree(s) Institution/Organization *Will your institution or organization require local IRB approval for this project? Unsure

3 Page 3 Step 3 - Funding and Publication 23. *How will this project be funded? Choose one: By a not-for-profit organization or governmental agency By a private company, such as a pharmaceutical or device manufacturer By an academic institution By a private practice Other: 24. *Based on your responses, it is likely that the annual subscription fee to access RISE data will be waived for this project. However, this does not guarantee that the fee will be waived as determinations for waivers are made on a case-by-case basis during the review process. Please indicate that you are aware that if your request is approved but the subscription fee is not waived, you or your organization will be required the pay the fee before proceeding with the project. I understand 25. *Based on your responses, it is likely that the annual subscription fee to access RISE data will NOT be waived for this project. However, this does not guarantee that the fee won't be waived as determinations for waivers are made on a case-by-case basis during the review process. Please indicate that you are aware that if your request is approved but the subscription fee is not waived, you or your organization will be required to confirm that this year's fee has been paid before proceeding with the project. I understand 26. If you are applying for a grant to fund this project, what is the application deadline? 27. What is your expected budget for the RISE data analyses proposed in this project? (This information will be used to assess the project s feasibility.) Reminder: You are required to include an acknowledgement of the RISE Registry in all publications, abstracts, manuscripts and presentations that make use of RISE data. The recognition language can be found under Analyzing RISE Data on the ACR's Requesting RISE Data webpage.

4 Page 4 Step 4 - Research Proposal 28. *Title of Research Proposal 29. *Hypothesis and/or Statement of Intent Provide a brief statement (500 character limit) describing the proposal s main hypothesis. Limit to no more than two aims. 30. *Background/Significance Provide a brief statement (1,000 character limit) describing the background and significance of the proposed research.

5 Page 5 Step 5 - Required Data 31. *Inclusion and Exclusion Criteria Briefly describe the proposal s patient inclusion and exclusion criteria. (1,000 character limit) 32. *Data Requested, including Primary Outcomes and Covariates Delineate groups for comparison and list the primary and secondary outcomes of interest for this proposal. Also, list any requests for modeling these outcomes, any covariates of interest and any of the main variables that may need to be considered (e.g., for adjustment) in the analysis. You can review the different types of data available in the RISE Data Dictionary. (1,000 character limit)

6 Page *Data Analytic Center Assistance the budget allows. Do you anticipate needing the center's help building and/or revising the analytic plan? 34. *Brief Statistical Analysis Plan 35. Step 6 - Data Analysis If this project is approved, the assigned data analytic center will work collaboratively with the requestor to refine the analytic plan appropriately to best suit the data available. However, the time allotted for such work in each project is limited. The centers can provide more extensive support building and/or revising the analytic plan, if Provide a brief description of the proposed statistical methodology that could be considered for your proposal based on the data requested. If you are requesting assistance from the assigned data analytic center, provide your initial expectations on how the analysis will be completed. (1,000 character limit) You can upload one supporting document you would like to include with your request. (e.g. flowchart, table templates, etc.) Select file to upload... Allowed file type(s):.csv,.doc,.docx,.pdf,.ppt,.pptx,.txt,.xls,.xlsx

7 Page 7 Step 7 - Review Please review the information you provided for your data request. Once done, click the "Finish" button. (User Survey Response)