AQ UALITATIVE EVALUATION OF THE LATE EFFECTS CLINIC AT THE BEATSON

							School Research Ethics Committee

Application Form for projects NOT requiring
NHS approval

This form must be submitted as part of your application.

NAME

DESIGNATION

INSTITUTION

ADDRESS

EMAIL ADDRESS

TELEPHONE NUMBER

STUDENT NO.
(where relevant)

SUPERVISOR

FUNDING BODY
(where relevant)

PROJECT TITLE

PROJECT PROPOSED START DATE

PROJECT PROPOSED COMPLETION
DATE



APPLICANT’S SIGNATURE

SUPERVISOR’S SIGNATURE
(where relevant)

ADDITIONAL COMMENTS FROM
SUPERVISOR INCLUDED

DATE




Application Form                                           Page 1 of 2
School Research Ethics Committee

Application Checklist Form


This form must be submitted as part of your application.

1 copy of the SREC application form and an electronic version with all supporting
documentation are required.

Applications will only be processed on receipt of the appropriate documents.


Please
mark

            This form: The completed SREC application form

            Patient information sheet

            Written consent forms

            Interview schedules/questionnaires

            Research tracking form

            Others (please specify)



Please also ensure that patient information sheets, letters and other documents are on headed
paper and have version numbers and version dates recorded on them.

Please return this checklist together with your application form to the address below:


John Paley
c/o Sarahjane Gilvear
R.G Bomont Building
School of Nursing, Midwifery & Health
University of Stirling
STIRLING FK9 4LA

Telephone:         01786 466404
Email:             nm.research@stir.ac.uk


Application Form                                                                   Page 2 of 2
STUDY TITLE:




RESEARCH TEAM:

(Please provide details beginning with the principal investigator and including the names and
affiliations of co-applicants. Students should list themselves as PI and supervisors as ‘co-
applicants’).



  Principal Investigator/student:

  Co-applicants/supervisors:

     1.

     2.

     3.

     4.

     5.

     6.
Please complete the following, ensuring that the font is Times New Roman, Ariel or Calibri
and is no smaller than point 11 in size. The default on this form is set at Ariel 11.

BACKGROUND AND RATIONALE (not to exceed 500 words)
AIMS
(Please extend this section to the length required to discuss your aims and research
questions)




STUDY DESIGN
(Please extend this section to the length required to fully discuss your study design.)
POPULATION AND SAMPLE
(Please extend this section as required.)




DATA COLLECTION
(Please extend this section as required.)
ANALYSIS
(Please extend this section as required.)




POTENTIAL RISKS AND SAFEGAURDS
(Please extend this section as required.)




INFORMED CONSENT
(Please extend this section as required.)
RESEARCHERS’ ROLE
(Please extend this section as required.)




SENSITIVE TOPICS
(Please extend this section as required.)




CONFIDENTIALITY AND ANONYMITY
(Please extend this section as required.)
DATA HANDLING
(Please extend this section as required.)




OTHER RESEARCH ETHICS COMMITTEES
(Please extend this section as required.)




MAIN ETHICAL ISSUES
(Please extend this section as required.
REFERENCES
(Please extend this section as required.)




APPENDICES
Please attach copies of information sheets, consent forms, questionnaire(s), interview
schedule(s), a copy of the letter from NHS ethics if applicable.
Tracking Projects




Project Title
Project Number/Cost Centre
Project Description
Principal Investigator
Principal’s Department and
University

Will Ethical Review be
Sought?                          Yes                     No 
Reasons if No
Authorised by

All Staff Employed in Project
Other Investigators
(University of Stirling)
Other Investigators
(External)
Financial Year                   Start Date           End Date
Funds Awarded

Funding Body
(In Full)
Total Amount Requested           £            Total Amount   £
                                              Awarded
Eligible for inclusion in RAE?

Extension Date                   Additional Funds     £




Tracking Projects                                                Page 1 of 2
Programme
Links to Other Programmes
Research Group or Centre
(if applicable)

Contact Person
(Research Assistant)
Key Words

                            submitted   accepted   unacceptable   Date
Interim Report                                        
Final Report                   




Tracking Projects                                                 Page 2 of 2




Form revised August 2011