NewProtocolApplication：新协议的应用.doc

NewProtocolApplication：新协议的应用.docFormFHS013:Newprotocolapplicationform一sectionAGeneralinformationProtocoltitleInvestigator(s)profileUCTsprincipalinvestigator(PI)Title,firstname,surnameDepartment/DivisionPhoneEmailaddressOfficemailingaddressRegistrationwithHPCSA□Yes□No Registration#Note:Ifanon・medicallytrainedPIisoverseeingresearchwhichinvolvesmedicalprocedures,theapplicationmustincludeamedicaldoctorregisteredwiththeHPCSAasaco--basedprincipalinvestigator,co--investigator(s)Title,firstname,surnameDepartment/DivisionE-?(Totalnumberforallresearchprojects)OpenresearchstudiesSites(excludingthisapplication)CoinvestigatorsNumberofparticipantsWhatisthePl'sroleinauthoringthisprotocol?(tick7)PrimaryauthorCollaboratorNone(developedbysponsors)Arethereanypublicationrestrictionsontheresearch?□No |□YesIfyes,pleasedescribeandjustify:?(tickP)□No □YesIfyes,plete:,hasthisprotocolbeenrejectedbyanotherHREC?(tick7)□No□Don'tknow口YesIfyes,pleaseprovidethereasons:?(-study,follow-upstudy,earlierphasetrial)?(tick7)□No □YesIfyes,plete:?(tickV)□No □YesIfyes,pleasespecify:TypeofdegreeStudentsnameande-mailSupervisor'snameande-?(tick7)□No |□YesIfno,-relatedadverseevents(tickP)□NA(・minimalriskresearch,medicalrecordreview)□No□YesIfyes,pleasedescribe:pliantcorporateinsuraneepolicyUCTsno-?(tickV)□Yes |口NoIfno,(tick7atleastone)Nofunding/sponsor->-funded(,eTrust,BillandMelindaGatesFoundation)USFederalfunding(,CDC)UCT():(Industry-sponsore