[Letterhead]

[Date]

Dear HREC,

Re: Submission of new Ethics Application

I wish to submit the following research proposal, for review by:

Human Research Ethics Committee (TQEH/LMH/MH)
Royal Adelaide Hospital Research Ethics Committee

HREC reference number (if already allocated)
Short title*
Full title*

Low risk review*	Yes No

Application type*	Single-site	Multi-site

Study type*
FTIH/FTIP Clinical Trial - Drug	FTIH/FTIP Clinical Trial - Device	FTIH/FTIP Clinical Trial - Drug & Device
Clinical Trial of a Drug	Clinical Trial of a Device	Clinical Trial of a Drug & Device
Clinical Trial (Other)	Clinical Research	Health Research/Social Science
Other (please state)

Major sponsor type*
Commercially Sponsored Collaborative Group Investigator Initiated Institution Other

Commercially sponsored studies only*
Name of the sponsor organisation/CRA/CRO

Mode of HREC review*	State	National Mutual Acceptance

Clinical trial phase* (if applicable)
Phase 1 Phase 2 Phase 3 Phase 4 First time in Human First time in Patients Not Applicable

NHMRC category*

Site Name	State	Principal Investigator
If more sites, please insert row(s) below

Supporting documents submitted and uploaded to Online Forms (include version dates and/or numbers)
Document Name	Version date	Version No	Hardcopy Attached	Uploaded online
If more documents, please insert row(s) below; record X to indicate submitted/uploaded

Studies involving the use of ionising radiation (for each document type, indicate the number submitted)
For all sites where radiation exposure is additional to normal clinical management/care: Medical Physicist’s report

Other relevant information for the HREC

Yours sincerely,

[Name]

Coordinating Principal Investigator