test research form

Home

test research form

Research Office Registration Form - Amended Version October 2022

Form used by research office for grant applications, clinical trial applications, MOU etc

Registering your project sets in motion a request for services. There are 5 options:
1. Pre-Feasibility registration - registering a Commercial Trial at pre-feasibility stage.
2. Memorandum of Understandings (MOUs) - requesting an MOU between an external organisation and the CDHB.
3. Locality Authorisation only – solely applying for Locality Authorisation to undertake research using CDHB resources eg. Non CDHB-hosted clinical trial.
4. Grant application – requesting assistance with all aspects of grant applications.
5. Clinical Trial – registering CDHB-hosted commercial or other clinical trials.
Note: An asterisk * next to a form field means that the information required is mandatory and must be completed.
What do you require assistance with?*
- Pre-Feasibility registration
- MOU
- Locality Authorisation only
- Grant application
- CDHB Hosted Clinical Trials

Pre-Feasibility registration
Please fill out this form if you are registering a CDHB Clinical Trial at pre-feasibility stage.
What Departments are involved in this research?*
Enter the names of the CDHB departments involved in your project.
CDHB Research Coordinator Details
CDHB Research Coordinator Name*
This must be CDHB staff member
CDHB Research Coordinator Contact Details*
Please enter their contact phone number and email address
Additional contacts to be notified of registration
Please enter their names followed by a contact phone number and email address.
Project Details
Brief Project Title*
What type of clinical trial research agreement will this be?*
- Sponsor
- CRO
- Collaborative
- Don't know
Phase of trial*
- Phase I
- Phase II
- Phase III
- Phase IV
- Unknown
Sponsor Details
Who have you been approached by?*
Check here to see if a Master CDA is in place with this Sponsor.
Is there is a master CDA in place for this sponsor ?*
- Yes
- No
Untitled*
- I acknowledge that I am aware that information sent by this Sponsor will be subject to the confidentiality provisions contained in the relevant Master CDA.
Research Form ID
MOU
Please fill out this form if you are undertaking an MOU between an external organisation and the CDHB.
What Departments are involved in this research?*
Enter the names of the CDHB departments involved in your project.
Canterbury DHB (CDHB) resource or person to be contracted
CDHB Researcher Name/CDHB Resource*
CDHB Researcher Role*
- Student
- RMO
- SMO
- Allied Health
- Nursing
CDHB Researcher contact details*
Please enter their contact phone number and email address
CDHB Researcher/Resource Department*
Other Investigators and Departments
Lead Site and Principal Investigator
Is Canterbury DHB the lead site?*
- Yes
- No
Principal Investigator Name*
Principal Investigator Role*
- Student
- RMO
- SMO
- Allied Health
- Nursing
Principal Investigator Organisation*
Principal Investigator Department*
Phone Number*
Email Address*
Lead site research office details
Please list your research office advisor and their contact details
Registration Contact
Please provide contact details for the person completing this registration.
Registration Contact Name*
Registration Contact Email*
Project Details
Project Title*
Please include a protocol number if applicable.
Expected project start date*
DD slash MM slash YYYY
Expected project end date*
DD slash MM slash YYYY
Briefly provide a lay summary of your project*
Limit to 100 words
Anticipated number of patients involved*
- N/A
Total number of CDHB FTE involved*
- N/A
Is this a Phase I trial?*
- Yes
- No
Research Impact/Outputs
What are the expected outputs from your project?*
- Publication
- Conference presentation
- Other
Other*
If Other, please describe this
Funding Details
Name of grant*
Name of funder*
Grant registration closing date
DD slash MM slash YYYY
Grant application closing date*
DD slash MM slash YYYY
Research Office closing date*
The Research Office need to have received an email from the Service /Line Manager with approval of the requested FTE by this date in order for approvals to be signed off in time

DD slash MM slash YYYY

The Research Office need to have received an email from the Service /Line Manager with approval of the requested FTE by this date in order for approvals to be signed off in time.
Will CDHB be a signatory for any funding contract(s) relating to this project?*
- Yes, there will be CDHB contracts for this project
- No, contracts will not be signed by CDHB
- N/A
Value of external funding coming to the CDHB?*
Mental Health
Will you be utilising CDHB Specialist Mental Health Services by accessing our patients, patient data or staff?*
- Yes
- No
Locality Authorisation only
Please fill out this form if you are solely applying for Locality Authorisation to undertake research using CDHB resources eg. Non CDHB hosted clinical trial.
Departments involved in the research
What Departments are involved in this research?*
Canterbury DHB (CDHB) Lead Investigator and other CDHB contacts
Lead Investigator Name*
Lead Investigator Role*
- Student
- RMO
- SMO
- Allied Health
- Nursing
Lead Investigator Contact Details*
Please enter their contact phone number and email address
Lead Investigator Department*
Contact details for communication about this project
Lead Site and Principal Investigator
Is Canterbury DHB the lead site?*
- Yes
- No
Principal Investigator Name*
Principal Investigator Role*
- Student
- RMO
- SMO
- Allied Health
- Nursing
Principal Investigator Organisation*
Principal Investigator Dept*
Principal Investigator Phone Number*
Principal Investigator Email Address*
Project Details
Project Title*
Please include a protocol number if applicable.
Expected project start date*
DD slash MM slash YYYY
Expected project end date*
DD slash MM slash YYYY
Briefly provide a lay summary of your project*
Limit to 100 words
Anticipated number of patients involved*
- N/A
Total number of CDHB FTE involved*
- N/A
Is this a Phase I trial?*
- Yes
- No
If Yes, please provide the link to the ANZCTR for this trial*
Is CDHB patient data being sent externally from the CDHB?*
- Yes
- No
Research Impact/Outputs
What are the expected outputs from your project?*
- Publication
- Conference presentation
- Other
Other*
If Other, please describe this
Funding Details
Will the project involve funding sources external to CDHB?*
- No external funds
- Yes, it will involve fund sources external to the CDHB
Enter name of fund source/organisation(s) providing funding*
Will CDHB be a signatory for any funding contract/subcontract(s) relating to this project?*
- Yes, there will be CDHB contracts for this project
- No, contracts will not be signed by CDHB
- N/A
Value of external funding coming to the CDHB*
Mental Health
Will you be utilising CDHB Specialist Mental Health Services by accessing our patients, patient data or staff?*
- Yes
- No
Ultra low risk project screening
Is this request ONLY to use HNZC resources to advertise for participants?*
- Yes
- No
Please give details of how you wish to recruit (flyer in waiting/staff room, poster on noticeboard, email distribution list, etc.)
Is this request ONLY to use a HNZC venue (e.g. to host a hui/focus group, conduct an interview, etc.)?*
- Yes
- No
Low risk project screening
Will your data collection be retrospective or prospective? (if a combination of both, please select prospective)*
- Retrospective
- Prospective
Please tick the following statements that are appropriate to your project*
- You are not accessing HNZ Canterbury patient information to contact a patient
- This is NOT a clinical trial
- There is at least one member of HNZ Canterbury staff affiliated with this project
- This project only requires access to data
- Research does not involve mental health services or will not require breaking the privacy seal in the electronic medical record
- HNZ Canterbury staff time is in their CME or approved by their line manager (or equivalent)
- There is no financial contracting to enter into with the HNZ Canterbury
Grant
Please fill out this form if you are applying for an externally funded grant.
Departments involved in the research
What Departments are involved in this research?*
Canterbury DHB (CDHB) Lead Investigator and other CDHB contacts
Lead Investigator Name*
Lead Investigator Role*
- Student
- RMO
- SMO
- Allied Health
- Nursing
Lead Investigator Contact Details*
Please enter their contact phone number and email address
Lead Investigator Department*
Other Investigators and Departments
Lead Site and Principal Investigator
Is Canterbury DHB the lead site?*
- Yes
- No
Principal Investigator Name*
Principal Investigator Role*
- Student
- RMO
- SMO
- Allied Health
- Nursing
Principal Investigator Organisation*
Principal Investigator Department*
Phone Number*
Email Address*
Project Details
Project Title*
Please include a protocol number if applicable
Briefly provide a lay summary of your project*
Limit to 100 words
Funding Details
Name of grant*
Name of funder*
Grant registration closing date
DD slash MM slash YYYY
Grant application closing date*
DD slash MM slash YYYY
Research Office closing date*
The Research Office need to have received an email from the Service /Line Manager with approval of the requested FTE by this date in order for approvals to be signed off in time.

DD slash MM slash YYYY

The Research Office need to have received email approval from the Service/Line Manager regarding FTE by this date in order for approvals to be signed off in time.
Will CDHB be a signatory for any funding contract(s) relating to this project?*
- Yes, there will be CDHB contracts for this project
- No, contracts will not be signed by CDHB
- N/A
CDHB Hosted Clinical Trial
Please fill out this form if you are undertaking a CDHB hosted clinical trial eg. Sponsor, CRO or Collaborative
Feasibility reference number
Please provide the reference number provided if you registered pre-feasibility
What Departments are involved in this research?*
Canterbury DHB (CDHB) Lead Investigator and other CDHB contacts
Lead Investigator Name*
Lead Investigator Role - CDHB Hosted Clinical Trial*
- Student
- RMO
- SMO
- Allied Health
- Nursing
Lead Investigator Contact Details*
Please enter their contact phone number and email address
Lead Investigator Department*
Other Investigators and Depts
Key Contact Person*
CDHB Research Coordinator Details
Research Coordinator Name*
Must be CDHB staff member
Research Coordinator Contact Details*
Please enter their contact phone number and email address
Please enter the Research Coordinators contact phone number and email address
Additional contacts to be notified of registration
Please enter their names followed by a contact phone number, email address and postal address
Is this a multi-centre trial?*
- Not a multi-centre trial
- Multi-centre-CDHB NZ lead site
- Multi-centre-CDHB sub-site
Lead Site and Principal Investigator
Is Canterbury DHB the lead site?*
- Yes
- No
Principal Investigator Name*
Principal Investigator Title*
Principal Investigator Organisation*
Principal Investigator Department*
Phone Number*
Email Address*
Project Details
Project Title*
Please include a protocol number if applicable.
Expected project start date*
DD slash MM slash YYYY
Expected project end date*
DD slash MM slash YYYY
Briefly provide a lay summary of your project*
Limit to 100 words
Number of patients involved*
- N/A
Total number of CDHB FTE involved*
- N/A
What type of clinical trial research agreement will this be?*
- Sponsor
- CRO
- Collaborative
Phase of trial*
- Phase I
- Phase II
- Phase III
- Phase IV
- Unknown
Please provide a link to the ANZCTR for this trial*
Research Impact/Outputs
What are the expected outputs from your project?*
- Publication
- Conference presentation
- Other
Other*
Funding Details
Enter name of fund source/organisation(s) providing funding*
Approximate total budget*
Comments
This field is for validation purposes and should be left unchanged.

Page last updated: 10 October 2022

Is this page useful?

VISITING HOSPITAL

For visitors to all facilities effective from Friday 16 September 2022

Kia whakahaumaru te whānau, me ngā iwi katoa – this is to keep everybody safe:

Visiting patients with COVID-19

All of our Hospitals

test research form

Research Office Registration Form - Amended Version October 2022

Pre-Feasibility registration

CDHB Research Coordinator Details

Project Details

Sponsor Details

MOU

Canterbury DHB (CDHB) resource or person to be contracted

Lead Site and Principal Investigator

Registration Contact

Project Details

Research Impact/Outputs

Funding Details

Mental Health

Locality Authorisation only

Departments involved in the research

Canterbury DHB (CDHB) Lead Investigator and other CDHB contacts

Lead Site and Principal Investigator

Project Details

Research Impact/Outputs

Funding Details

Mental Health

Ultra low risk project screening

Low risk project screening

Grant

Departments involved in the research

Canterbury DHB (CDHB) Lead Investigator and other CDHB contacts

Lead Site and Principal Investigator

Project Details

Funding Details

CDHB Hosted Clinical Trial

Feasibility reference number

Canterbury DHB (CDHB) Lead Investigator and other CDHB contacts

CDHB Research Coordinator Details

Lead Site and Principal Investigator

Project Details

Research Impact/Outputs

Funding Details