State Center for Health Statistics - NC DHHS
North Carolina CHAMP Data User Annual Report Form
|USER INFORMATION |
|Name | |
|Title/Position | |
|Affiliation | |
|Email Address | |Telephone # | |
|IRB INFORMATION |
|Has an Institutional or Human Subjects Review Board (IRB) approved the research project using NC-CHAMP data? | Yes No N/A |
|Name of IRB or Human Subjects Review Board | |
|IRB Study Protocol # | |IRB Approval Date | |
|PRESENTATIONS: List all public presentations using results based on NC-CHAMP data. Include all presentations, posters, reports, and public communications. |
| |
|PUBLICATIONS: List all papers accepted for publication using NC-CHAMP data. Provide complete citations. Include all manuscripts, reports, fact sheets, and |
|surveillance updates released to the public. |
| |
|GRANTS: List all grants that have been awarded to use NC-CHAMP data. |
| |
|ANNUAL REPORT DUE JUNE 30: |
|Submit completed form to the CHAMP Survey Coordinator at CHAMPStaff@dhhs. |
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State Center for Health Statistics
Child Health Assessment and Monitoring Program (CHAMP)
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