Manual Short Form- Health and Labour Questionnaire (SF-HLQ)

Appendix III REGISTRATION FORM FOR THE USE OF THE SF-HLQIn order to be able to assess by whom this questionnaire is used and to what purpose, werequest you please to complete this form and return this to the address belowDate:………………………………………………………………………………………Name:……………………………………………………………………………………….Organization/institution:…………………………………………………………………….Address:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Postcode:……………………………………………………………………………………Place:…………………………………………………………………………………….Telephone number:…………………………………………………………………………Fax number:………………………………………………………………………………E-mail address:………………………………………………………………………………Purpose of the study:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Are you using other measurement instruments next to the SF-HLQ (If so, which others?)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What is the approximate size of the proposed study population?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………When will you be finished with the study?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Dr. L. Hakkaart-van Roijeninstitute for Medical Technology AssessmentErasmus University RotterdamPostbox 17383000 DR Rotterdame-mail: hakkaart@bmg.eur.nl33