The Research Project Insurance Application

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The following information will be required in order to make an individual insurance assessment.

Please complete table below and submit.

(Office use only) Application ID
Academic Unit and Discipline conducting Research:
Title of Research Project:	Click or tap here to enter text.
Contact person name and number:	Click or tap here to enter text.
Project commencement date:	Click or tap to enter a date.
Project completion date:	Click or tap to enter a date.
Purpose of project (summary):	Click or tap here to enter text.
In what countries will you be conducting your research?	Click or tap here to enter text.
Is this research a Clinical Trial? For Insurance Purpose: Clinical Trial means any research study, healthy volunteer study or observational study undertaken to evaluate the effects on health outcomes, that complies with the statutory requirements or guidelines of the relevant person, authority, department or public or private body in the country in which the Trial takes place. If yes, does the Clinical Trials focus on the trial of pharmaceutical and medical devices on research subjects being undertaken by or on behalf of the University. If yes, describe nature of the pharmaceutical and medical devices.	Yes ☐ No☐ Yes ☐ No☐ Click or tap here to enter text.
Is this research required to be notified under the "Clinical Trial Notification" or "Clinical Trial Exemption" Schemes?	Yes ☐ No☐
Total number of participants/volunteers:	Click or tap here to enter text.
Description of any treatment or testing to be undertaken on participants (e.g. blood sampling, medical testing, exercise stress testing etc.)	Click or tap here to enter text.
Who will be conducting the treatment or testing on the participants? (e.g. UniSA students/staff/volunteers, hospital staff, external medical practitioners?)	Click or tap here to enter text.
Does the research project involve the administration of drugs/minerals/vitamins etc?	Click or tap here to enter text.
If yes - is the drug/mineral/vitamin TGA approved?	Click or tap here to enter text.
Are consent forms completed by participants:	Click or tap here to enter text.
Is the research project sponsored by a third party? If yes, please advise by whom:	Click or tap here to enter text.
Is there an agreement with any third party? e.g. Hospital, aged care facility, government body etc.	Click or tap here to enter text.
Has this Research Project received prior approval from an external ethics committee? If yes, please advise by whom:	Yes ☐ No☐
Any other information or disclosures relevant to your application:	Click or tap here to enter text.
**Please only hit the ‘Submit’ button once. No pop up message will appear after submitting. **Please note if submitting the Research Project Insurance Application while accessing VPN system, you will be required to 'Save As' the completed document before attaching to email and send to insurance@unisa.edu.au