microsoft word - heiq registration form web viewregistration form . below. a. licen. c. e . ......
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Registration FormAll sections and versions of the HLQ are copyrighted and may only be used with permission from the authors; this includes translation of the HLQ into other languages. A database of registered HLQ users is maintained to ensure that copyright is not breached. To be able to use the HLQ, you will need to obtain a licence from Deakin University. To obtain a licence, please complete the registration form below.
A licence processing fee of AUD250 (plus GST for Australian users) must be paid.
Complete the form and return it to [email protected] .
Please Note: a licence request cannot be generated without a fully completed form
1. Chief Investigator responsible for the project / supervisor of student (Title, full name, full address, email)
2. Authorised officer (person who can authorise payment and sign licence agreement on behalf of the organisation seeking a licence)
Title: Full name: Name of entity for licence*: ABN (or relevant business registration number): Address: Country: Email*: Website: Phone number:
* Important: The HLQ licence can only be issued to an organisation, a legal entity, not an individual and non-institutional email addresses are not acceptable. That is, the application will be rejected if gmail, yahoo or other non-institutional emails are provided.
3. Type of organisation (tick all that apply):
Hospital/Medical PracticeResearch organisation (University or Institute)Commercial organisationThe Health Literacy Questionnaire (HLQ). © Copyright 2014 Deakin University. Authors: Richard Osborne, Rachelle Buchbinder,
Roy Batterham, Gerald Elsworth. No part of the HLQ can be reproduced, copied, altered or translated without the permission of the authors.Further information: [email protected]
Updated July 2015 1
Other (please specify):4. List of other investigators/student: (Title, full name, address, email)1.
2.
5. Student waiver:If the use of the HLQ is exclusively for a single Masters or PhD student project, the supervisor may apply for a licence fee discount. Evidence of studentship must be provided by an institutional representative.
6. Describe the project where the HLQ will be usedName of project:
Design, subjects, disease type, intervention, methods:
7. Start date of project:8. End date of project:9. Project funding (Funding entity / Amount):
10.
a) Total number of respondents in study:
b) Number of administrations per respondent: c) Total number of times the HLQ will be
administered across study (a x b)*:
* Note: a licence is based on a single project basis. Provide a single total number only.
11. Language*: English Arabic Chinese (Simplified) Chinese (Trad) Czech Danish Dutch French (France) French (Canada) German Greek Hindi Indonesian Italian Malaysian Norwegian Portuguese (Brazil) Romanian Slovak Somali
Spanish (Argentina) Spanish (Spain) Vietnamese Yoruba (Nigeria)
Other (list):
*Note: Additional languages may be available – contact [email protected]. Translation and adaptation can only be done under licence and in collaboration with
The Health Literacy Questionnaire (HLQ). © Copyright 2014 Deakin University. Authors: Richard H Osborne, Rachelle Buchbinder,Roy Batterham, Gerald R Elsworth. No part of the HLQ can be reproduced, copied, altered or translated without the permission of the authors.
Further information: [email protected]
Updated October 2015
Deakin University using the HLQ translation protocol. Conditions and fees apply.
12. For the purposes of building an international community of practice, are you willing for the Investigator’s contact details to be made available to other organisations or researchers working in a similar field, region or language?
Yes No
13. We are conducting research into the sensitivity, validity and reliability of the HLQ, and aim to provide benchmarks for the HLQ to assist researchers and organisations to understand their results. Are you willing to be contacted about participating in these research and development projects?
Yes No
Please ensure that all information provided above is valid and accurate as they will used for the issuance of your HLQ licence agreement.
The Health Literacy Questionnaire (HLQ). © Copyright 2014 Deakin University. Authors: Richard H Osborne, Rachelle Buchbinder,Roy Batterham, Gerald R Elsworth. No part of the HLQ can be reproduced, copied, altered or translated without the permission of the authors.
Further information: [email protected]
Updated October 2015