Researcher Type Researcher Type Individual Researcher Group of Researchers

Name of Researcher

Researcher's Email

Researcher's Title and Credentials

Name of Collective Group

Names, Titles, and Emails of Applying Researchers

Requesting Department or School

Study Title

Please describe your study objectives and aims.

Please describe how this cohort of data will meet your study needs.

Please describe your study's importance to Medicaid and its beneficiaries.

Have you received funding for your study? Have you received funding for your study? Yes No Application(s) pending

Funding Source(s)

Additional Information