{"id":11495,"date":"2025-10-15T08:41:49","date_gmt":"2025-10-15T06:41:49","guid":{"rendered":"https:\/\/support.mrdm.com\/?post_type=codman&#038;p=11495"},"modified":"2025-10-15T08:42:28","modified_gmt":"2025-10-15T06:42:28","slug":"registration-form","status":"publish","type":"codman","link":"https:\/\/support.mrdm.com\/en\/codman\/codman-connect\/application-procedure\/registration-form\/","title":{"rendered":"Registration Form"},"content":{"rendered":"\n<p>Through this request form, you can apply for Codman Connect for yourself and collaborating healthcare institutions.<\/p>\n\n\n\n<p>Once MRDM has received this completed request form, MRDM will draft a contract for the participating healthcare institutions. After all participating institutions have signed this contract, Codman Connect will be activated.<\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f308-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"308\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/codman\/11495#wpcf7-f308-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"308\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f308-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:308,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;time-period&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;indicators&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dashboard&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Codman Indicators&quot;}]},{&quot;then_field&quot;:&quot;exploratory&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dashboard&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Codman Exploratory&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;-1&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;no&quot;,&quot;animation_intime&quot;:&quot;200&quot;,&quot;animation_outtime&quot;:&quot;200&quot;,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:&quot;&quot;,&quot;notice_dismissed_rollback-cf7-5.5.6&quot;:true,&quot;notice_dismissed_rollback-cf7-5.6&quot;:true,&quot;notice_dismissed_rollback-cf7-5.6.4&quot;:true,&quot;notice_dismissed_rollback-cf7-5.7.4&quot;:true,&quot;notice_dismissed_rollback-cf7-5.8.6&quot;:true,&quot;notice_dismissed_rollback-cf7-5.9.7&quot;:true}}\" \/>\n<\/fieldset>\n<!-- Applicant -->\n<div class=\"block\">\n<div class=\"inner\">\n\n  <h4>Your Details<\/h4>\n\n  <div class=\"field\">\n    <label>Your Name *<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"applicant-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"applicant-name\" \/><\/span>\n  <\/div>\n\n  <div class=\"field\">\n    <label>Your Email Address *<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"applicant-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email light\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"applicant-email\" \/><\/span>\n  <\/div>\n\n   <div class=\"field\">\n    <label>What is the name of the collaboration? *<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"collaboration\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Collaboration\" value=\"\" type=\"text\" name=\"collaboration\" \/><\/span>\n  <\/div>\n\n<\/div>\n<\/div>\n<!-- Applicant -->\n\n\n<!-- Registration -->\n<div class=\"block\">\n<div class=\"inner\">\n\n  <h4>Request Connect for<\/h4>\n\n  <div class=\"field checkbox horizontal\">\n    <label>Select which dashboard you want to request Codman Connect for. You can select both.<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"dashboard\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dashboard[]\" value=\"Codman Indicators\" \/><span class=\"wpcf7-list-item-label\">Codman Indicators<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dashboard[]\" value=\"Codman Exploratory\" \/><span class=\"wpcf7-list-item-label\">Codman Exploratory<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n<\/div>\n\n<div data-id=\"indicators\" data-orig_data_id=\"indicators\"  class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"inner block\">\n\n  <h4>Codman Indicators<\/h4>\n\n  <div class=\"field checkbox dropdown horizontal\">\n    <label>For which registration(s) do you want to request Codman Connect?<\/label>\n    <div class=\"checkbox-dropdown-field\">Select registration(s)<\/div>\n    <div class=\"checkbox-dropdown-options\"><span class=\"wpcf7-form-control-wrap\" data-name=\"indicatoren-registratie\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"indicatoren-registratie[]\" value=\"account,survey,batch,codman,breast-cancer,ichom\" \/><span class=\"wpcf7-list-item-label\">Breast cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"indicatoren-registratie[]\" value=\"sign-up,account,downloads,survey,codman,epsa,ernica\" \/><span class=\"wpcf7-list-item-label\">EPSA<\/span><\/label><\/span><\/span><\/span><\/div>\n    <div class=\"checkbox-dropdown-overlay\"><\/div>\n  <\/div>\n\n  <div class=\"field checkbox\">\n    <label>Which indicators do you want to share?<\/label>\n    <p>(this choice applies to all previously selected registrations)<\/p>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"share\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"share[]\" value=\"Mandatory transparent indicators\" \/><span class=\"wpcf7-list-item-label\">Mandatory transparent indicators<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"share[]\" value=\"Voluntary transparent indicators\" \/><span class=\"wpcf7-list-item-label\">Voluntary transparent indicators<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"share[]\" value=\"Internal indicators\" \/><span class=\"wpcf7-list-item-label\">Internal indicators<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n<\/div>\n<\/div>\n<div data-id=\"exploratory\" data-orig_data_id=\"exploratory\"  class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"inner block\">\n\n  <h4>Codman Exploratory<\/h4>\n\n  <div class=\"field checkbox dropdown horizontal\">\n    <label>For which registration(s) do you want to request Codman Connect?<\/label>\n    <div class=\"checkbox-dropdown-field\">Select registration(s)<\/div>\n    <div class=\"checkbox-dropdown-options\"><span class=\"wpcf7-form-control-wrap\" data-name=\"exploratief-registratie\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"exploratief-registratie[]\" value=\"account,survey,batch,codman,breast-cancer,ichom\" \/><span class=\"wpcf7-list-item-label\">Breast cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"exploratief-registratie[]\" value=\"sign-up,account,downloads,survey,codman,epsa,ernica\" \/><span class=\"wpcf7-list-item-label\">EPSA<\/span><\/label><\/span><\/span><\/span><\/div>\n    <div class=\"checkbox-dropdown-overlay\"><\/div>\n  <\/div>\n\n<p>When you request Connect for Exploratory, all results from Codman Exploratory are shared. This includes both transparent and non-transparent data. Additionally, all filters (except for clinician filters) are available for both your own and shared data. If 10 patients or fewer remain for a collaborating healthcare institution, the result will not be shown.<\/p>\n\n<\/div>\n<\/div>\n<\/div>\n<!-- Registration -->\n\n\n<!-- Time Period -->\n<div class=\"block\">\n<div class=\"inner\">\n\n  <h4>Time Period<\/h4>\n  <p>How long do you want to use Codman Connect? After this period, the functionality will automatically stop. Your regular Codman dashboards will remain active. If nothing is entered, a default of 3 months will be assumed. Codman Connect will be activated within 2 weeks after receiving all signed DocuSign contracts.<\/p>\n\n  <div class=\"field radio\">\n    <label>For which period do you want to use Codman Connect?<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"time-period\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"time-period\" value=\"Indefinite\" \/><span class=\"wpcf7-list-item-label\">Indefinite<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"time-period\" value=\"12 months\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">12 months<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"time-period\" value=\"3 months\" \/><span class=\"wpcf7-list-item-label\">3 months<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"time-period\" value=\"1 month\" \/><span class=\"wpcf7-list-item-label\">1 month<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"time-period\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<div data-id=\"other\" data-orig_data_id=\"other\"  class=\"\" data-class=\"wpcf7cf_group\">\n  <div class=\"field\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"other-period\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" autocomplete=\"off\" aria-invalid=\"false\" placeholder=\"Other\" value=\"\" type=\"text\" name=\"other-period\" \/><\/span>\n  <\/div>\n<\/div>\n<\/div>\n<\/div>\n<!-- Time Period -->\n\n\n<!-- Applicant -->\n<div class=\"block\">\n<div class=\"inner\">\n\n  <h4>Participating Institutions<\/h4>\n  <p>For which healthcare institutions do you want to activate Codman Connect? All institutions will receive identical functionality according to the wishes outlined in this form.<\/p>\n\n<h6>Required Information:<\/h6>\n\n<ol>\n<li>Names of the healthcare institutions participating in the Codman Connect collaboration (including your own institutions)<\/li>\n<li>Names and email addresses of the contact persons within the healthcare institutions who will ensure that the Codman Connect contract is signed by an authorized person<\/li>\n<\/ol>\n\n<p>Note: all institutions with which you want to share data must be explicitly listed below, including the contact person. Without this information, the request cannot be processed.<\/p>\n\n  <div class=\"field\">\n    <label>Participating Institutions<\/label>\n    <p>Example: DICA Hospital, Frank de Jong, fdejong@dica.nl; Medical Center MRDM, Ronald Jansen, rjansen@mrdm.nl<\/p>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"institutions\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" autocomplete=\"off\" aria-invalid=\"false\" placeholder=\"Participating Institutions\" name=\"institutions\"><\/textarea><\/span>\n  <\/div>\n\n   <div class=\"field\">\n    <label>Are there institutions that differ from the functionalities filled in on this form?<\/label>\n    <p>This could include an institution that does not want to participate in a certain registration or for a shorter time period<\/p>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"deviations\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" autocomplete=\"off\" aria-invalid=\"false\" placeholder=\"Deviations\" name=\"deviations\"><\/textarea><\/span>\n  <\/div>\n<\/div>\n<\/div>\n<!-- Applicant -->\n\n<!-- Info -->\n<div class=\"block\">\n<div class=\"inner\">\n<ul>\n<li>By filling in this form, you consent to the use of this data by MRDM<span class=\"conditional set-has-dica\"> and DICA<\/span>.<\/li>\n<li>The purpose of using this data is limited to communication regarding participation in the registration(s) for which there is a collaboration between your organization and MRDM<span class=\"conditional set-has-dica\"> and DICA<\/span>.<\/li> \n<li>The individuals known through this document can at any time request correction, deletion, or access to the data held by the Service Desk.<\/li>\n<li>The data will not be shared with third parties and is stored at MRDM as long as a collaboration exists between your organization and MRDM<span class=\"conditional set-has-dica\"> and DICA<\/span>.<\/li>\n<li>MRDM is ISO 27001:2013 and NEN 7510:2011 certified, ensuring the secure processing of personal data.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hcap-cf7\">\t\t<input\n\t\t\t\ttype=\"hidden\"\n\t\t\t\tclass=\"hcaptcha-widget-id\"\n\t\t\t\tname=\"hcaptcha-widget-id\"\n\t\t\t\tvalue=\"eyJzb3VyY2UiOlsiY29udGFjdC1mb3JtLTdcL3dwLWNvbnRhY3QtZm9ybS03LnBocCJdLCJmb3JtX2lkIjozMTIxNzc3fQ==-b3714789027c6f8ebf3b00c04797fbfb\">\n\t\t\t\t<span id=\"hcap_cf7-69ea6f170b7820.86232479\" class=\"wpcf7-form-control h-captcha \"\n\t\t\tdata-sitekey=\"16310c4e-78ea-428a-97c4-0237baf70ce2\"\n\t\t\tdata-theme=\"light\"\n\t\t\tdata-size=\"normal\"\n\t\t\tdata-auto=\"false\"\n\t\t\tdata-ajax=\"false\"\n\t\t\tdata-force=\"false\">\n\t\t<\/span>\n\t\t<input type=\"hidden\" id=\"_wpnonce\" name=\"_wpnonce\" value=\"2572270f33\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/codman\/11495\" \/><\/span><input class=\"wpcf7-form-control wpcf7-submit has-spinner bg-color-primary bg-hover txt-color-white\" type=\"submit\" value=\"Submit\" \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"parent":11003,"menu_order":0,"template":"","class_list":["post-11495","codman","type-codman","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/codman\/11495","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/codman"}],"about":[{"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/types\/codman"}],"version-history":[{"count":1,"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/codman\/11495\/revisions"}],"predecessor-version":[{"id":11496,"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/codman\/11495\/revisions\/11496"}],"up":[{"embeddable":true,"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/codman\/11003"}],"wp:attachment":[{"href":"https:\/\/support.mrdm.com\/en\/wp-json\/wp\/v2\/media?parent=11495"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}