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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