Yes No Multi-Centre Project(s) or Trial(s) Institution: __________________ Instructions: If yes, please list all participating institutions & Institution: __________________ centers. Institution: __________________ Ethics Approval Attached Yes No SECTION 9 VESTED INTEREST & CONFLICT OF INTEREST – Vested Interest Instructions: Please provide declare any vested interest held, either intellectual or financial, direct or indirectly (consultancy, shareholding, options, etc) by the Research Team (PI, mentor, co-investigator or collaborator). This includes declaring if the therapeutic/medical device or any part of it is invented by a member of the Research Team. Team Vested Interest Description Member Lead PI [name] Co-I [name] Instructions: If there is any vested interest for any of the Research Team members, pleases describe the nature of such interest and the measures undertaken to prevent/minimise any bias in the proposed clinical trial. Conflict of Interest Instructions: Please provide the names and contact information of individuals who might have conflict of interests with your current research proposal. Name Details of Conflict of Interest Email Address or Position Phone Number Institution or Organization Mr John Doe johndoe@sg-uni.edu.sg Head of Research 9876-5432 Singapore University SECTION 10 RECOMMENDED EXTERNAL REVIEWERS – Instructions: Please provide the names and contact information of at least 3 individuals who have the subject matter expertise to review your research proposal.
Multi-Centre Project(s) or Trial(s) Instructions: If yes, please list all participating institutions & centers. Yes No Institution: __________________ Institution: __________________ Institution: __________________ Ethics Approval Attached Yes No SECTION 9 – VESTED INTEREST & CONFLICT OF INTEREST Vested Interest Instructions: Please provide declare any vested interest held, either intellectual or financial, direct or indirectly (consultancy, shareholding, options, etc) by the Research Team (PI, mentor, co-investigator or collaborator). This includes declaring if the therapeutic/medical device or any part of it is invented by a member of the Research Team. Team Member Vested Interest Description Lead PI [name] Co-I [name] Instructions: If there is any vested interest for any of the Research Team members, pleases describe the nature of such interest and the measures undertaken to prevent/minimise any bias in the proposed clinical trial. Conflict of Interest Instructions: Please provide the names and contact information of individuals who might have conflict of interests with your current research proposal. Name or Position Institution or Organization Details of Conflict of Interest Email Address Phone Number Mr John Doe Head of Research Singapore University johndoe@sg-uni.edu.sg 9876-5432 SECTION 10 – RECOMMENDED EXTERNAL REVIEWERS Instructions: Please provide the names and contact information of at least 3 individuals who have the subject matter expertise to review your research proposal.
SMF%20Grant%202018%20Edition%20-%20A2CT%20Clinical%20Trial%20Application%20Form.docx