UHS Sponsor Request Form Version 2.0 16th Oct 2015 Section 1 To be completed for all projects requesting UHS to act as Sponsor – Study title Proposed dates Start Date: End date: Length of Follow-up: Is the project educational? Please Specify NB Not to be used for undergraduate No Yes Doctorate Masters projects. Chief Investigator contact details (for educational projects insert lead academic supervisor) Title/Name Principal employer: Work Address: Department Telephone CI holds UHS Honorary Contract: Yes Applying No Principal Investigator for UHS site contact details (for educational insert student investigator) Title Name Principal employer: Work Address: Department Telephone PI holds UHS Honorary Contract: Email Yes Applying No Is this a study of a medical device(s), investigational medicinal product (IMP) or an invasive technique? Please tick all that apply. Please state Medical device IMP Invasive technique None MHRA Risk Category How many participants will be recruited? Please specify UHS Patients UHS Staff Healthy Volunteers Other Patients Will the study involve UHS resources, premises? Please Specify No Yes Section 2 Funding details, to be completed for all projects – Is the research or will the research be in receipt of any external funding? Please specify how costs will be covered: Yes No
UHS Sponsor Request Form Version 2.0 16th Oct 2015 Section 1 – To be completed for all projects requesting UHS to act as Sponsor Study title Proposed dates Start Date: End date: Length of Follow-up: Is the project educational? NB Not to be used for undergraduate projects. No Yes Please Specify Doctorate Masters Chief Investigator contact details (for educational projects insert lead academic supervisor) Title/Name Principal employer: Work Address: Department Telephone CI holds UHS Honorary Contract: Yes Applying No Principal Investigator for UHS site contact details (for educational insert student investigator) Title Name Principal employer: Work Address: Department Telephone PI holds UHS Honorary Contract: Email Yes Applying No Is this a study of a medical device(s), investigational medicinal product (IMP) or an invasive technique? Please tick all that apply. Medical device IMP Please state MHRA Risk Category Invasive technique None How many participants will be recruited? UHS Patients UHS Staff Healthy Volunteers Other Patients Please specify Will the study involve UHS resources, premises? No Yes Please Specify Section 2 – Funding details, to be completed for all projects Is the research or will the research be in receipt of any external funding? Yes No Please specify how costs will be covered: