Name *	First:   Last:   Degree:
Title *
Organization
Department
Address *
City *	State *       Zip Code *
Country *	E-Mail *
Telephone *	Fax

Please check the category that best describes you: *

Health Researcher Health Practitioner Health Administrator Health Insurer Policy maker Educator

Student Librarian Media Consumer Other

1)	Study population:
	a) child    parent    both
	b)  Age range of children under study
	c)  Clinical condition(s) under study
	d)  Target sample size
	e) inpatient    outpatient    both

2)	Project purpose: (check all that apply)
	assess the health of general populations of children with asthma
	monitor the health of general populations of children with asthma over time
	inform resource allocation decisions
	evaluate impact of broad-based interventions or policies
	evaluate efficacy and effectiveness of clinical therapies and practices
	other (please specify):

3)	Brief project description: *

4)	Intervention to be measured: Please provide a brief description if your project involves a specific intervention (eg, pharmaceutical, education, medical, rehab, surgery, mental health, etc):

5)	Project time frame:  From    to

6)	Other measurement instruments to be used in this project:

7)	CHSA instruments you plan to use:
CHSA (parent-completed)
	self-administered
	interviewer-administered (in person)
	interviewer-administered (telephone)
CHSA Child Version
	interviewer-administered (in person)
	self-administered

8)	Planned recall period for the Children's Health Survey for Asthma (parent completed):
	2-week
	4-week
	8-week
	Only using the CHSA-C

9)	Language CHSA version(s) to be used: (check all that apply)
	English
	US Spanish
	Only using the CHSA-C

This agreement is for use of the Children's Health Survey for Asthma (CHSA) Version 3.1 and Children's Health Survey for Asthma (CHSA) Version 3.1 - US Spanish Translation, and the Children's Health Survey for Asthma-Child Version 1.1 (CHSA-C). All versions of the CHSA are copyrighted and may not be modified, retyped, abridged, condensed, translated into another language, adapted for another medium (computer/internet), reformatted, sold to others, or transformed in any manner, including wording and/or organization without prior written consent from the authors.

After acknowledging this Copyright Agreement and completing the online registration process, you are welcome to use the CHSA and/or the CSHA-C in your non-commercial research or individual practice and make copies of it for that purpose. Please include the copyright notice on all reprinted copies of the CHSA and/or CHSA-C. If you choose to use the CHSA and/or the CHSA-C, we would greatly appreciate learning of your results and receiving any feedback you might have about the instrument. The CHSA and CHSA-C may be used only by persons whom you employ or whom you engage as independent contractors. We ask that you refer colleagues and other professionals interested in the CHSA and/or the CHSA-C to us, rather than sharing your copy of the instrument. Our contact information is provided below.

CAUTION: Versions of the CHSA and the CHSA-C available from any source other than the AAP are unauthorized and may contain errors and scoring inaccuracies. These questionnaires should not be used.

* - required fields

I agree to the conditions established in this Copyright Agreement. *

Name: *
Title: *
Date: *

Have you requested information about the Children's Health Survey for Asthma or the Academy's Child Health Measurement Project (formerly the Functional Outcomes Project) in the past?             Yes
            No