+44 (0)7376 920341 enquiries@inspiredoutcomes.co.uk

Licence Request Form

To obtain permissions to use any of the Clinical Outcomes Assessments (COAs) we (IHO) manage you will need to complete a copyright licence agreement with us. To achieve that we need some information from you about your proposed use of the COA. The information you provide to us is captured in the form below. We will use it to create the licence for you.

The information you provide to us in the form below will be used by InSpired Health Outcomes Limited (IHO) as the basis for a legally binding licence of copyright agreement. So, please make sure that the details you provide are accurate.

The person who commits to taking the licence of copyright in the required COA must be an authorised signatory of the licensee.

Any information provided as part of this process will be treated in accordance with IHO’s Website Privacy Policy.

What will happen once you’ve completed this licence request application form? IHO aims to respond to your request within 24 hours, either with the ready to sign © licence agreement (this will be sent to you via DocuSign – so please do check you have provided us with the correct email address where you wish to receive the agreement) or you will receive a request(s) for further information. If we send a licence for signing to you, we will make it clear in that communication if any fees are due and how much. Once the licence is completed, we will send you all the relevant files for your licensed use of the COA(s) you have selected, to you via email.

At any stage of this process you can contact us for further clarification by emailing: enquiries@inspiredoutcomes.co.uk

About the COA(s) you wish to use and how you wish to use it / them:

1) Which COA(s) do you wish to use?

2) Territory / territories the COA(s) is / are going to be used in?

3) Please provide a brief description of the proposed use of the COA(s), along with any unique study identifier code(s) (e.g., ClinicalTrials.gov NCT number) if available.

4) Do you intend to deploy the COA(s) digitally (as an ‘eCOA’) for subject / participant / respondent completion?

Yes

5) Study Start date?

6) Study end date? (We automatically grant an extension of 6 months to allow for study overrun)

7) Number of subjects / participants / respondents enrolled in your study? (If you do not currently know the number of subjects, for example, it’s a registry study, then please estimate or declare 1000+).

8) Number of times each subject / participant / respondent will be asked to complete the COA(s) during the study?

About your organisation:

9) What type of organisation is taking the licence of copyright? Please select one of the following that most accurately describes your employer / organisation / institution:

10) Name of your organisation – the entity taking the © licence

11) Address of your organisation

12) VAT number (for organisations registered in the EU and UK)

13) If fees are applicable, please provide any information to assist in processing of the invoice, for example trial number or PO number.

About you (as the lead contact for the licence):

14) Your last (family) name

15) Your first (given) name

16) Your title (Professor, Dr, Mr, Ms, Mrs etc.)

17) Your job title

18) Your email address

19) Your telephone number (please include country and local area codes):

20) How did you come to learn about this PRO?

Licence Request Form

About the COA(s) you wish to use and how you wish to use it / them:

About your organisation:

About you (as the lead contact for the licence):

Get In Touch