Application for Ethical Review Renewal

Application for Ethical Review Renewal
Approval Details
What is the Ethical Review Number (ERN) for the project?
Investigators
Please provide details of the principal investigators or supervisors
Name
First NameLast Name
Position Held and Highest Qualification
School
Department
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Please provide details of any co-investigators or co-supervisors
Name
First NameLast Name
Position Held and Highest Qualification
School
Department
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Project Details
Project Title
Estimated Start Date
MonthDayYear
Date
Estimated End Date
MonthDayYear
Date
Project Summary
Write as stated in the initial application
Progress to Date
We expect a concise summary of progress to date
Summary of Any New Ethical Considerations
ie. Not covered by current approval

Variations and Amendments

Rows	Yes	No
Have there been any additions or variations/amendments to the research protocol?
Are there any additions or variations/amendments to the research protocol for which you wish to obtain approval?

Declaration by Applicants
This application is made on the basis that the information is confidential and will be used by the REC for the purposes of ethical review and monitoring of the research project described herein, and to satisfy reporting requirements to regulatory bodies. The information will not be used for any other purpose without my prior consent.
I declare that:
• The information provided in this form together with any accompanying information is complete and correct to the best of my knowledge and belief and I take full responsibility for it.
• I will report any changes affecting the ethical aspects of the project to the responsible officer.
• I will report any adverse or unforeseen events which occur to the relevant committee.
Date
MonthDayYear
Date
Signature of Principal investigator/project supervisor:
Clear
Should be Empty:

Approval Details