Untitled Document

	Cohort Application Form Please complete all fields in the form below to be considered for inclusion in the NA-ACCORD

1. Cohort Name, Country and Geographical Region

2. Contact Details
Contact Person:
Address:
Phone:
Email:
Website:
3. Cohort Description
	3a. General description (please indicate if interval/classic or clinical cohort and include specific research aims,as well as a list of recruitment sites):

	3b. Cohort enrollment dates :

4. Data Collection
	4a. Types of data collected:
	Data category		Examples		Specific data collected under each category
	Demographic		Age, sex, ethnicity, etc.	Yes No
	Clinical		HIV/AIDS events (defining or associated), OIs, disease stage, etc.	Yes No
			Other clinical events: co-infections, cardiovascular, etc.	Yes No
	Therapeutic		Current ART treatment, ART history, etc.	Yes No
			Concurrent treatments	Yes No
	Laboratory		HIV associated (viral loads, CD4, CD8, etc.)	Yes No
			Non HIV associated (lipids,etc.)	Yes No
	Socioeconomic		Employment, education, family size	Yes No
	Health services utilization and administration		Types of insurance, appointments kept/missed, etc.	Yes No
	Adherence		Patient self-report, interview, etc.	Yes No
	Other		Reasons for loss from follow up, causes of death, etc.	Yes No
	Additional Comments:

	4b. Data collection interval:
		Follow up interval:
		Interval of CD4 and viral load determination:

	4c. Data collection methodology:
	Methodology
	Prospective data collected through in-person interviews				Yes No
	Prospecitve data collected through structured questionnaires				Yes No
	Prospecitve data collected through medical records				Yes No
	Retrospecitve data collected through medical records				Yes No
	Any other. Please specify.				Yes No

	4c. Data quality:
			Examples		Specific data monitoring process
	Data quality monitoring		Data source verification, random sapling, periodic review	Yes No

5. Population Characteristics
	5a. Inclusion criteria:


	5b. Exclusion criteria:


	5c. Number of individuals enrolled to date (please include current date):


	5d. Cohort characteristics:
			Females %
			Averg age at enrollment/first visit: yrs
			Percent of patients on ART treatment in Sept 2004: %

			Risk category
			MSM %
			IDU %
			Heterosexual %
			Perinatal transmission %
			Other/unknown risk category %

			Race/Ethnicity
			Caucasian %
			African American %
			Asian %
			Latino %
			Other/Unknown %

			Annual loss to follow up (include your definition of loss to follow up):


			Proportion of patients with known date of seroconversion within a window of 1 year:

6. Research Interests
			Adherence to therapy		Yes No
			Mortality and causes of death		Yes No
			Toxicity and adverse event studies		Yes No
			Pharmacokinetic drug interactions		Yes No
			Economic and outcome analysis		Yes No
			HIV epidemiology		Yes No
			Resistance in therapy naive patients		Yes No
			Resistance in therapy experienced patients		Yes No
			Treatment outcome		Yes No
			Any other (specify)

7. Primary collaborators and participating organizations:


8. Funding Sources:


9. Publiation Information:
	9a. Please provide publication(s) that can be used as a reference for the cohort:


	9b. Source for obtaining the complete publication list (website/email address)


10. Cohort Management Team

	Name		Position/Role		Degrees