Research

Title

Agreements notification form

Agreements notification

Please use this form to submit your new Agreement or amendment. Please attach relevant files to this webform

*Declaration	By submitting this form I declare that the information provided above is true and accurate. And all necessary attachments accompany this report form This is a mandatory field.
*Principal Investigator	This is a mandatory field.
Principal Investigator Email
*Email address for correspondence	This is a mandatory field.
Contact email of the Party Contracting with Austin Health
LEX ID (if known)
*Lead HREC Project Number	This is a mandatory field.
SSA Reference Number (if applicable)
Protocol Number/Short title
*Project Title (Long title)	This is a mandatory field.
Funding source
Information about international partnership	if applicable
Other funding source details	if selected other in funding source
Agreement Type
Agreement Description	Provide a brief description of • Project feasibility assessment completed (including impact on staffing levels) • Relevant risk management • Any financial considerations
Expected income and/or outbound expenditure
Conflict of Interest(s	Outline the investigator’s name and the conflict of interest including whether it is a one-off occurrence or whether it has an ongoing, recurring or cumulative nature
Intellectual Property (IP)	If applicable, please provide a brief description of: • Existing/background IP of Austin Health • Third party IP • Project IP • Whether there is a possibility of commercialisation and potentially valuable IP
Commercialisation	If applicable, please outline if there is potential to commercialise anything in relation to this project
Third Party Providers e.g., laboratories, statisticians, regulatory consultants, external staff	If applicable, please list all third-party providers
Attach word copy of agreement

Research

Austin Health

Research

Agreements notification form

Agreements notification

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