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					                     Application Form for Expedited Ethical Review
Principal Researcher



Associate Researcher/Student Researcher


Department/Institution



Campus/Address


Email                                                          Telephone:
Project Title:




Category          Quality Assurance                                     Low Risk Study
Why are you seeking Expedited Review?




How does this activity qualify as “low risk”?




Documents Attached
   Lay Summary
   Participant Information Sheet (if no PIS please indicate why not)
   Consent form to Participate in Research (if no CF please indicate why not)
   Protocol (including hypothesis and aims)
   Questionnaire(s) – if applicable                  Signature of Researchers
   CV (if not a Mercy employee)                      Signature of hospital Department Head
                                                      Signature indicating Divisional support
                                                      Signature of Hospital Manager/DON
Ethics Approval already received from (other institutions) ………………………………………………..
Resource Implications (e.g. pathology or other costs pls specify)
Signatures:

Principal Researcher:                  ……………………………………………………………..


Associate Researcher :                 ……………………………………………………………..


Associate Researcher :            ……………………………………………………………..
(copy for additional researchers)


Hospital Department Head:              ……………………………………………………………..


Clinical Director (Medical):           …………………………………………………………….


Clinical Director (Nursing):           …………………………………………………………….


Hospital Manager/DON:                  ……………………………………………………………..




    Ensure that you attach your supporting documents and the Q.A. and/or the Low Risk Study Checklist to
    this application form before submitting it. You are encouraged to lodge your application by email.
    Applications lodged electronically will be processed within 2 weeks; however, the processing of
    applications lodged in hard copy may take longer.                 Please email your application to
    vkaritinos@mercy.com.au or if you are unable to email your application you should forward 4 copies to:
              Vicky Karitinos
              Secretary, Research Ethics Committee
              C/- Mercy Hospital for Women
              163 Studley Road
              HEIDELBERG, VIC. 3084

                                                         Office Use Only

Accepted for expedited review                                accepted for expedited review
                                                              Not

Project Number ……………………

Allocated to : 1 ………………………………..                2. …………………………….                     3. …………………………

Date sent ……/……/…….                                                    Application Approved
Response required by ……/……/……                                          Application Not Approved

 Email approval advice sent to Principal Investigator

				
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posted:8/5/2011
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Jun Wang Jun Wang Dr
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