Data and Analytic Support Questionnaire

The Hilltop Institute works with public and non-profit community-based agencies at the national, regional, and local levels to improve the health and social outcomes of vulnerable populations in a manner that maximizes the impact of available resources.

Please complete the information below. All fields are required.

Organization:
Name:
Email:
Phone:

Estimated Hilltop Start Date:               Estimated Hilltop End Date:

Provide a brief description of the proposed project.

How does the proposed project fit within Hilltop's mission, above?

What is the intended role for Hilltop researchers and/or analysts?

Are MD Medicaid data being requested?   Yes   No

If Yes, how does the proposed project advance DHMH's mission to address the healthcare needs of Medicaid beneficiaries?

If data from external sources (e.g., Medicaid, Medicare, MDS, HSCRC, etc.) are being requested, has permission from the covered entity been secured?   Yes   No

If Yes, please provide the applicable IRB number:   , or explain below.

Who is (are) the proposed funder(s) of the project?

What is the plan for dissemination of results, and for what purpose will they be used?