Request Access [International End-User]

Dear Doctor, Madam, Sir,

This form is used to provide the responsible person within your organisation the information needed to provide you access to the applications of healthdata.be (HD4DP v2 and healthstat.be). After completion your request will be sent by healthdata.be to this responsible person. You will receive an email notification of successful submission of your request, and when your access was granted.

More information about this request process can be found in this manual. If you encounter problems during this process, you can contact us via our online service platform.

Organisation for which one asks access

Full name of the Organisation

Official address of the Organisation for which one asks access

Address

City/Town

ZIP/Postal Code

Country

Official contact person of the Organisation for which one asks access

Name of official contact person

Email of official contact person

Function of official contact person

First name of requestor

Last name of requestor

Work Email address of requestor

Mobile phone number

Country

Role of requestor in project

First name of responsible Local Study Associate

Last name of responsible Local Study Associate

Request access for the public health projects in:

HD4DP2.0

Healthstat.be

Access to helpdesk portal of healthdata.be required?

Does user wants to be informed when new reports are available on Healthstat.be?

CAPTCHA

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