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Repository: Request Access

Study Title

Long Form Title(Required)

Working Title(Required)

Application Information

Title

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Telephone Number(Required)

Email(Required)

Principle Investigator (If different from applicant)

Same as above

Principle Investigator Details

Title

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Telephone Number(Required)

Email(Required)

Sponsor

Budget related to this request (with justification)

Scientific and Ethics Review

Has there been external scientific review of this protocol?

Yes, this protocol was part of a larger peer-reviewed grant. Please describe the reviewing organization.

Yes, this protocol specifically was peer-reviewed. Please describe the reviewing organization and attach reviewer’s feedback.

No

Peer Review Details(Required)

Do you have research ethics approval for this study?

Yes – Which REBs have or will be reviewing this protocol?

In progress – Which REBs are reviewing this protocol?

Seeking REB review after DAC approval.

No – Please provide written correspondence with your REB indicating why not required.

External Review Details(Required)

Does this study have any proprietary or commercial element to it?

No

Yes

Please Describe(Required)

Project Details

Maximum 500 words

Background(Required)

[Describe the underlying clinical scenario / issue.]

Research Questions/Study Aims:(Required)

Data Fields Required

Demographic (e.g. age range, gender)(Required)

Diseases (List all relevant diseases)(Required)

Other

Medicines (List all relevant)(Required)

Please describe your sampling frame(Required)

Patient outcomes being measured(Required)

How will this research benefit people who are living with diabetes or the general public?(Required)

How will risks be mitigated?(Required)

In what way(s) have patients or their families or caregivers been involved in the planning of the research?(Required)

How are sex and gender issues being addressed in this study?(Required)

(See CIHR guidance: http://www.cihr-irsc.gc.ca/e/50836.html)

What are your plans for data linkage?

No plans for data linkage

Yes, plans for linkage. Please describe:

Data Linkage Information(Required)

Signature

Date

MM slash DD slash YYYY

Please attach Protocol, REB approval, scientific review feedback, and any other third-party feedback on the protocol.

File

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