Western Health Governance Cover Letter and Checklist

The site Principal Investigator should submit this Cover Letter & Checklist with the completed research governance/Site Specific Assessment (SSA) application to the site Research Governance Office (RGO).

Date: Select date

Dear WH RGO,

ERM ID Reference: E.g. 41234

HREC Reference Number (if known): E.g. HREC/18/ABC/123; HREC/41234/ABC-2018

Project title: Enter title

Applicant	Sponsor
Contact Person:	Enter text	Sponsor Name:	Enter text
Position:	Enter text	Contact person:	Enter text
Email:	Enter text	Address:	Enter text
Phone:	Enter text	Email:	Enter text
Phone:	Enter text

Relevant Information for RGO
Name of Reviewing Human Research Ethics Committee	Enter text
Name of Principal Investigator at WH site:	Enter text
Study Type:	Choose an item.
WH sites this SSA application applies to (check all boxes that apply): Sunshine Hospital ☐ Footscray Hospital ☐ Williamstown Hospital ☐ Sunbury Day Hospital ☐ Drug Health Services ☐ Hazeldean Transition Care ☐ Sunshine Radiation Therapy Centre ☐ Bacchus Marsh and Melton Regional Hospital ☐ Melton Health & Community Services ☐ Bacchus Marsh Community Health Centre ☐ Melton Health ☐ Grant Lodge Residential Aged Care ☐
Approximate number of patients being recruited at WH sites:	Enter number
Funding type: Commercial ☐ Collaborative Group Sponsored ☐ External Grants ☐ Internal Funding ☐ Other ☐ Specify: Enter text
Budget/Funding amount at WH site(if funded):	Enter Amount
Are you using any unapproved drugs or devices?	Yes ☐ No ☐ Go to Q9
If yes, please attach eCTN/eCTX print preview in landscape format Attached☐ Not attached ☐ Please explain why this has not been provided: Enter text
Anticipated duration of study:	Enter number Months
Please provide any additional relevant information to the RGO
Enter text

Yours sincerely,

Name

Position

Clearly list all documents being submitted– Duplicate page if more documents attached

IMPORTANT e-files should be clearly numbered to match the documents listed.

Email e-copy documents to ethics@wh.org.au. Hardcopies to be submitted to the WH Office for Research

Number	Document Name	Version	Date	Hardcopy	E-copy
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐
Enter Number	Enter document name	Enter version	Select date	Yes No	☐ ☐	Yes No	☐ ☐

If “No” has been selected for any of the documents, please clarify why a hardcopy or e-copy has not been provided. Please specify what documents are missing at time of submission.
Enter text