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Application for Access to the Dorenfest Institute for H.I.T. Research and Education Database Applicant

First Name: *
Last Name: *
Title (if any):
Organization:(university or government agency): *
Address: *
City: *
State: *
Zip Code: *
Phone: *
E-mail address: *

Which name best describes your role at your organization or agency (choose one)? *
Undergraduate student Graduate student Faculty Researcher Administrator Other

If you are a student, what is your course of study (e.g., Masters in Public Health)?


Please describe the project for which you will be using this database. Describe the general topic, distribution of, and goal of the project. *


What is the end product of this project (choose one)? *
Doctoral Thesis Masters Thesis Grant research Academic research paper White paper Book chapter or content Article Other

Do you plan to submit the end product for possible publication in a journal, magazine or book?
Yes No
If yes, what is the publication you will be submitting to?


Please the names of all individuals within your organization who will be working with you on this project and with whom you may be sharing access to this database.


Are you a HIMSS member?
YesNo

If your answer is ‘No,’ would you like to receive information on becoming a HIMSS member?
YesNo

Would you like to receive information on the HIMSS Foundation Scholarship program?
YesNo

Please carefully read the following Database Usage Agreement. If you understand and agree to the requirements of this agreement, please click ‘Yes’ for the boxes below.

Yes, I have read the Usage Agreement for the Dorenfest Institute for H.I.T. Research and Education Database and understand and agree to the requirements of that Agreement. Click to Read Usage Agreement

Yes, I agree to cite the source of the data I use as the Dorenfest Institute Database.


* Required information.