Clinician Reg Form - Keele Licencing

NHS/non-profit registration

Organisation Name(Required)

Email(Required)

Address(Required)

Street Address City County / State / Region ZIP / Postal Code Country

What is your role within the organisation?(Required)

After evaluating the tool, would you consider working with Keele University to implement and evaluate it in your clinical setting?(Required)

Yes

Where did you hear about the tool?(Required)

How do you intend to use the tool?

Clinical Practice within the NHS (e.g. General Practice, Family Practice, Orthopeadics, Rheumatology, Physiotherapy, Chiropractic, Osteopathy etc.)

Clinical Practice outside of the NHS or UK

Research Purposes

Credit Card(Required)

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Please specify the clinical population you will use the tool with(Required)

Please indicate whether you intend to use the tool as part of a stratified approach and do you have the appropriate matched treatments in place?(Required)

Please specify your intended research use for this tool (e.g. translation, cultural adaptation, external validation, other)(Required)

Briefly describe your commercial operation and how you intend to use the tool (.e.g. workers compensation, health insurance, other)(Required)

This agreement is between your organisation and the University of Keele, a university established by the University of Keele Act 1962 (10&11 Eliz.2 Ch Xv) and the granting of a Royal Charter in 1962 of Keele, Staffordshire ST5 5BG ("Keele") and sets out terms that the parties have agreed upon to cover the licensing arrangements for the STarT MSK Tool which is owned by Keele.

The License Agreement shall be effective for 12 months from registration. It may be terminated by either party upon one (1) months' written notice to the other Party.

Keele University may also collect personal information supplied through the use of web-based forms. This information will not be supplied to any third party, and will only be used for subsequent communications.

The data will be kept for no longer than is required and in compliance with DPA. In submitting your personal information online, you are agreeing that University staff may use your details for the sole purpose of conducting the business of the University.

If at any time you no longer wish to receive information from Keele University, please respond to any email and state that you wish to 'unsubscribe'.