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For Current Users of the QWB-SA


Contact Name:  
Phone Number:  
Organization / Company Name:  
Current Year of Copyright Agreement signed and sent to HSRC:  
Total number of questionnaire administration to date (both partial and completed administration):  

*A member of the HSRC staff will contact you if further information is needed.

Reminders –

The Copyright Agreement is only valid for the current year.
If you would like to continue using the QWB-SA for the next year, please email

Payment is due 30 days after the date of agreement was signed.
Please send payment to:
UCSD Health Services Research Center
9500 Gilman Drive, 0994
La Jolla, CA 92093-0994