The Data Use Agreement (DUA) is made by and between Westat and the group organization named below (hereinafter termed “Participating Organization”) and includes any practice listed below for which data will be submitted. If the Participating Organization represents more than one practice or site, include the name and address of EACH individual practice which is represented by the Participating Organization and therefore covered under this Data Use Agreement.
Participating Organization as Listed in item #1 in DUA:
|
Group ID (10 characters max.) |
Group or System Name (50 characters max.) |
Practice ID (10 characters max.) |
Practice Site Name (50 characters max.) |
Street Address 1 (30 characters max.) |
Street Address 2 (30 characters max.) |
City (30 characters max.) |
State (2 characters max.) |
|---|---|---|---|---|---|---|---|
