St Vincent’s Hospital
(Melbourne) Limited
ABN 22 052 110 755
41 Victoria Parade Fitzroy VIC 3065
PO Box 2900 Fitzroy VIC 3065
Telephone 03 9288 2211
Facsimile 03 9288 3399
www.svhm.org.au
St Vincent’s Hospital (Melbourne)
Institutional Biosafety Committee (IBC)
Application to Change Members of a Research Team
PROTOCOL DETAILS
IBC Protocol No
IBC Protocol Title
IBC Protocol Classification
IBC Protocol Approval Date
IBC Protocol Expiry Date
Principal Investigator
Person who completed this form
Email address
REMOVE Members from the Research Team
Name
Reason
ADD Members to the Research Team
Complete details below for each person to be included in this dealing
Name
Signature
Class
☐ Project supervisor
☐ Post-graduate student
☐ Research assistant
☐ Animal technician
☐ Post-doctoral researcher
☐ Other (please specify):
Please include a brief summary of experience relevant to this dealing:
Does this person require training to perform the procedures in this dealing?
☐
No
☐
Yes
Name of person responsible for training
Request to Change Members of the Research Team:
November 2013
Name
Signature
Class
☐ Project supervisor
☐ Post-graduate student
☐ Research assistant
☐ Animal technician
☐ Post-doctoral researcher
☐ Other (please specify):
Please include a brief summary of experience relevant to this dealing:
Does this person require training to perform the procedures in this dealing?
☐
No
☐
Yes
Name of person responsible for training
Name
Signature
Class
☐ Project supervisor
☐ Post-graduate student
☐ Research assistant
☐ Animal technician
☐ Post-doctoral researcher
☐ Other (please specify):
Please include a brief summary of experience relevant to this dealing:
Does this person require training to perform the procedures in this dealing?
☐
No
☐
Yes
Name of person responsible for training
Name
Signature
Class
☐ Project supervisor
☐ Post-graduate student
☐ Research assistant
☐ Animal technician
☐ Post-doctoral researcher
☐ Other (please specify):
Please include a brief summary of experience relevant to this dealing:
Does this person require training to perform the procedures in this dealing?
☐
No
☐
Yes
Name of person responsible for training
COPY AND PASTE PAGE IF REQUIRED
Request to Change Members of the Research Team:
November 2013