13. Registration Document

The registration form below is given as an example only. To register with the Global Asthma Network please visit our registration page

Instructions

1. Please complete the Global Asthma Network Registration Document to register as a Global Asthma Network Centre

2. If insufficient space has been provided, please use an appropriately numbered continuation page

3. Once completed, please retain a copy for your records and send a copy to the GAN Global Centre by fax, email, mail or complete on line.

Address: Philippa Ellwood, the GAN Global Centre, Division of Paediatrics, Faculty of Medicine and Health Science, University of Auckland, Private Bag 92019, Auckland New Zealand. Fax: 64 9 3737602. info@globalasthmanetwork.org or complete on line: http://www.globalasthmanetwork.org

Global Asthma Network Region:

____________________________________

Country Name _______________________________	Country Number _______
Centre Name ________________________________	Centre Number ________
1. Date of completion: _____________________

2. Principal Investigator details:

Name: __________________________________________________

Position: _________________

Institution: _____________

Postal Address: ____________ ________________________ ________________________	Telephone:
	Fax:
	E-mail:

3. Other main collaborators (Names, email addresses and role)

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Please state the name and email address of the person who will be the person that the GAN Global Centre communicates with regarding the study.

4. Basic details of the planned Global Asthma Network study

yes

a) Questionnaire to 13/14 year olds

(Compulsory core and environmental/management)

yes

b) Video questionnaire to 13/14 year olds

(International version (Strongly recommended)

yes

c) Questionnaire to parents of 13/14 year olds

(ADULTS) (Strongly recommended)

yes

d) Questionnaire for 6/7 year olds (parental completion)

(Strongly recommended)

yes

e) Questionnaire to parents of 6/7 year olds

(ADULTS) (Strongly recommended)

yes

f) Are you planning to add other assessments to your Protocol?

If YES, please provide brief details and send a copy of the questionnaires to the GAN Global Centre.

5. Other studies

Have there been prevalence studies of asthma, allergic rhinoconjunctivitis, atopic eczema, or other respiratory disease (particularly concerning children) in the chosen study area within the last 10 years?

If yes please give brief details

6. Data sharing

I agree that my data can be made available on the Global Asthma Network website following completion of the data analysis for the global publications.

Yes No

7. Declaration

I agree to undertake Global Asthma Network study in the manner described in the Global Asthma Network Manual.

Name (print):
Signature: _____________________________	Date: _____________________________

The Global Asthma Network strives for a world where no-one suffers from asthma

The Global Asthma Network is the asthma surveillance hub for the world

The Global Asthma Network researches ways of reducing the burden of asthma

The Global Asthma Network promotes access to appropriate asthma management

The Global Asthma Network stimulates and encourages capacity building in LMICs

The Global Asthma Network strives to ensure access to quality-assured essential asthma medications

The Global Asthma Network raises the profile of asthma as a major NCD

13. Registration Document