The following information will be required in order to make an individual insurance assessment.
Please copy and paste the table below into a word document, and complete.
| Write your Answers Here |
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| (Office use only) Application ID | |
| Academice Unit and Discipline conducting Research: | |
| Title of Research Project: | |
| Contact person name and number: | |
| Project commencement date: | |
| Project completion date: | |
| Purpose of project (summary): | |
| In what countries will you be conducting your research? | |
| Is this research a Clinical Trial? | |
| Is this research required to be notified under the "Clinical Trial Notification" or "Clinical Trial Exemption" Schemes? | |
| Total number of participants/volunteers: | |
| Description of any treatment or testing to be undertaken on participants (e.g. blood sampling, medical testing, exercise stress testing etc.) | |
| Who will be conducting the treatment or testing on the participants? (e.g. UniSA students/staff/volunteers, hospital staff, external medical practitioners?) | |
| Does the research project involve the administration of drugs/minerals/vitamins etc? | |
| If yes - is the drug/mineral/vitamin TGA approved? | |
| Are consent forms completed by participants: | |
| Is the research project sponsored by a third party?
If yes, please advise by whom: |
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| Is there an agreement with any third party? e.g. Hospital, aged care facility, government body etc. | |
| Any other information or disclosures relevant to your application: |