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Request Form for Adult Uncertainty in Illness Scale (Community Form) I request permission to copy the Adult Uncertainty in Illness Scale (Community Form) for use in my research entitled: ___________________________________________________________________ ___________________________________________________________________ In exchange for this permission, I agree to submit to Dr. Mishel, upon completion of the study, a printout of the uncertainty data on a 3.5-inch disk containing the data with the data dictionary. The data must contain information on each subject's age, sex, education, and diagnosis, along with data on each subject's response to each item on the Uncertainty Scale. This data will be used to establish a normative database for clinical populations. No other use will be made of the data submitted. Credit will be given to me in reports of normative statistics that make use of the data I submitted for pooled analysis. Credit will be given to me in any reports referring to my findings.                                                                               ___________________________ Signature ___________________________ Date Positions and full address of Investigator                 ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ Permission is hereby granted to copy the MUIS for use in the research described above.                                                                               ___________________________ Merle H. Mishel ___________________________ Date Please send two signed copies of this form to Merle H. Mishel, Ph.D., FAAN, School of Nursing, CB#7460 Carrington Hall, University of North Carolina, Chapel Hill, NC, 27599-7460.