Date form completed Month DATA ANALYSIS REQUEST Day

- Date form completed: - Month DATA ANALYSIS REQUEST Day Year NOTE: Form must be submitted at least 6 weeks before the results are needed. See item A. 4. Instructions: This form must be completed for all requests for data from the Data Coordinating Center. FAX the completed form to the DCC at 1 -800 -xxxx. A. Requester Information 1. Requester: 2. Clinical Site: Last Name First Name 3. Phone number: - 4. Date Needed: Month Extension Day Year 5. Which return format do you prefer: a E-mail b Fax c Other, specify: _____________________________________ 6. Which fax number? B. Purpose of Data Analysis (check all that apply): 1. Purpose of data analysis (check all that apply): a Local use only 2. Which local use(s)? a Local IRB or Quality Assurance b c Local presentation Other, specify: _______________________ GO TO ITEM B. 3 Purposes b, c, d, or e may be subject to Steering Committee approval. b Presentation for/to: ____________________________________ c Papers for: _______________________________________ d Abstract for: _______________________________________ e Other, specify: ______________________________________ 3. What is the scope of the request? a Specified clinical sites only: _________________________________ b All sites (may be subject to Steering Committee approval) C. Description of Requested Data 1. Which time period should be included? a All available data b The following period: Begin date: Month OPT Form 70 V 1 (1 -2) DEC 02 Day - End Date: Year Month Day Year

- Date form completed: Month Day Year 2. Is data needed for a modification, update, or reprint of a previous report? a Yes Attach first page of report 3. Are there any changes other than included dates? b No or unknown a Yes GO TO ITEM C. 4 b No STOP. Form is complete. Fax to Data Coordinating Center. 4. Use only a subset of subjects? a Yes b No Describe desired subset (examples: subject age over 35; race white; any drug addictions at baseline). 5. In what order would you like the data listed or grouped? (Example: by clinical site, by PID, by race, etc. ) 6. What data items would you like included? Include specific Form and Item numbers. (Example: Form 10, Item 60, Number of previous full-term births) 7. Additional information as needed. (Example: comments, sketch of table layout, etc. ) Attach additional pages as necessary. OPT Form 70 V 1 (2 -2) DEC 02