Standard Form of Indemnity Checklist Clause or Schedule Please check Has the Institution been defined as Indemnified Party” in the Yes “the clause? “To” Is the name of the Institution Health ABN 27 318 956 319 a Yes “Alfred body corporate established under the Health Services Act 1988 (Vic) of 3004”? Has the Sponsor been defined as “the Sponsor” in the “From” Yes clause? Has the full legal name of the Sponsor been listed, and their ABN Yes provided? Are the study title and protocol number correct in the clause? “Re” Yes Paragraph Number 1: Has the correct patient (patients of the Yes Indemnified Party or non-patient volunteers) been selected as “the Participants”? Paragraph Number 1: Has the correct name of the Principal Yes Investigator been inserted for Investigator”? “the Has the indemnity been defined as 3” or X”? Yes No “Schedule “Exhibit If so, this should be deleted as the signed indemnity should be separate to the CTRA/CIRA. HREC Review Only Indemnity Clause or Schedule Please check Has the Institution of the Reviewing HREC been defined as “the Yes Indemnified Party” in the “To” clause? If the Alfred Hospital Ethics Committee is the reviewing HREC is the Yes name of the Institution Health ABN 27 318 956 319 a body “Alfred corporate established under the Health Services Act 1988 (Vic) of Commercial Road, Melbourne 3004”? Has the Sponsor been defined as Sponsor” in the “the “From” Yes clause? Has the full legal name of the Sponsor been listed, and their ABN Yes provided? Are the study title and protocol number correct in the clause? Yes “Re” Paragraph Number 1: Has the correct patient group (patients of the Yes Indemnified Party or non-patient volunteers) been selected as “the Participants”? Paragraph Number 1: Has the legal name/s of the institution/s for Yes which the Reviewing HREC has oversight been listed? Paragraph Number 1: Has the correct name/s of the Principal Yes Investigator/s been inserted for Investigator”? “the Has the indemnity been defined as 3” or X”? Yes No “Schedule “Exhibit If so, this should be deleted as the signed indemnity should be separate to the CTRA/CIRA.
Standard Form of Indemnity Checklist Clause or Schedule Please check Has the Institution been defined as “the Indemnified Party” in the “To” clause? Yes Is the name of the Institution “Alfred Health ABN 27 318 956 319 a body corporate established under the Health Services Act 1988 (Vic) of 3004”? Yes Has the Sponsor been defined as “the Sponsor” in the “From” clause? Yes Has the full legal name of the Sponsor been listed, and their ABN provided? Yes Are the study title and protocol number correct in the “Re” clause? Yes Paragraph Number 1: Has the correct patient (patients of the Indemnified Party or non-patient volunteers) been selected as “the Participants”? Yes Paragraph Number 1: Has the correct name of the Principal Investigator been inserted for “the Investigator”? Yes Has the indemnity been defined as “Schedule 3” or “Exhibit X”? If so, this should be deleted as the signed indemnity should be separate to the CTRA/CIRA. Yes No HREC Review Only Indemnity Clause or Schedule Please check Has the Institution of the Reviewing HREC been defined as “the Indemnified Party” in the “To” clause? Yes If the Alfred Hospital Ethics Committee is the reviewing HREC is the name of the Institution “Alfred Health ABN 27 318 956 319 a body corporate established under the Health Services Act 1988 (Vic) of Commercial Road, Melbourne 3004”? Yes Has the Sponsor been defined as “the Sponsor” in the “From” clause? Yes Has the full legal name of the Sponsor been listed, and their ABN provided? Yes Are the study title and protocol number correct in the “Re” clause? Yes Paragraph Number 1: Has the correct patient group (patients of the Indemnified Party or non-patient volunteers) been selected as “the Participants”? Yes Paragraph Number 1: Has the legal name/s of the institution/s for which the Reviewing HREC has oversight been listed? Yes Paragraph Number 1: Has the correct name/s of the Principal Investigator/s been inserted for “the Investigator”? Yes Has the indemnity been defined as “Schedule 3” or “Exhibit X”? If so, this should be deleted as the signed indemnity should be separate to the CTRA/CIRA. Yes No
Non-investigator-initiated-checklist.docx