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Request for Translation and Non-Commercial Use

Please select surveyes that you would like permissions for translation and complete the request form along with the uploaded declaration page with your signature. An email will be sent to you after your request is verified and approved. 

Copyrighted material is available free of charge to those individuals who have a full-time academic appointment at an academic or other non-profit research institution for non-commercial purposes. You may use and make copies of the copyrighted material for your research. You may not use the copyrighted material for commercial purposes without the written consent from the provider. Commercial purposes include sale, lease, license, or other transfer of the copyrighted material to a for-profit organization. Commercial purposes shall also include uses of the copyrighted material or modifications by any organization, to perform contract research, to produce or manufacture products for general sale, or to conduct research activities that result in any sale, lease, license, or transfer of the copyrighted material or modifications to a for-profit organization. If you are interested in using the survey for commercial purposes, please submit commercial user enquiry form. 

Product Selection

Lymphedema Symptom Intensity and Distress Survey:

  • Arm v2.0
  • Lower Limb v1.0
  • Head & Neck v2.0
  • Truncal v1.0

Please provide the initial licensee information requested in this form, and a representative will contact you to review licensing options for your organization.

Contact Information

Please provide the following information:

First Name

Phone Numbers

Please provide some information regarding the organization requesting...

Please describe your organization.


Please select your role within the organization.


You've indicated that you are a student. Please provide degree as well as the contact information for your PI.

Please provide your degree (BA, MA, PHD, etc.) and Major.

Please provide your PI's full name.

Please provide your PI's e-mail.

Please describe your role within the Organization.

Request Details

Please provide the following details regarding your inquiry so that we may better assist you.

Please describe the type of projects for which this survey will be used for.

Pleas state the expected duration of the project for which survey will be used

Plate describe the purpose of the project e.g. Title of the research study, duration of study, number of study participants involved, funding source, and geographic location of the study, etc.

Please state where you hear about the about VU Kidney Health Surveys?

Do you have any additional questions/comments or feedback for the developers of the survey?

Permission Request and Declaration for non commercial translation

Please download the following questionnaire - complete, sign and upload before submitting your request.

Please upload the signed Permission Request and Declaration for non commercial translation form before submitting.