HREC Reference Number Allocation Request This form is required only if you wish to be allocated a HREC reference number prior to submission. Please fill out ALL sections and return to HREC Committee: TQEH Trial Research Ethics Committee (TQEH/LMH/MH) – RAH Royal Adelaide Hospital Research Ethics Committee – Study type: Other Study Type FTIH/FTIP Clinical FTIH/FTIP Clinical Trial FTIH/FTIP Clinical Trial Drug & – – – Drug Device Device Clinical Trial - Drug Clinical Trial - Device Clinical Trial - Drug & Device Clinical Trial (Other) Clinical Research Health Research/Social Science Other(Please state) Application Type: Single Site Multi Site Short Title: (max 70 characters) Long Title: CPI/PI Name: Study Coordinator Name: Study Coordinator Phone: HREC Ref: HREC/ / / (to be completed by Ethics Officer)
HREC Reference Number Allocation Request This form is required only if you wish to be allocated a HREC reference number prior to submission. Please fill out ALL sections and return to HREC Committee: TQEH – Research Ethics Committee (TQEH/LMH/MH) RAH – Royal Adelaide Hospital Research Ethics Committee Study type: Other Study Type FTIH/FTIP Clinical Trial – Drug Clinical Trial - Drug Clinical Trial (Other) Other(Please state) FTIH/FTIP Clinical Trial – Device Clinical Trial - Device Clinical Research FTIH/FTIP Clinical Trial – Drug & Device Clinical Trial - Drug & Device Health Research/Social Science Application Type: Single Site Multi Site Short Title: (max 70 characters) Long Title: CPI/PI Name: Study Coordinator Name: Study Coordinator Phone: HREC Ref: (to be completed by Ethics Officer) HREC/ / /
HREC-number-allocation-form-v2.docx