Version 3.4
EOI NO:
Date Received ___/____/_____
Electronic File Name:
EXPRESSION OF INTEREST
For Research Proposals
BRIEF TITLE OF PROJECT
LEAD INVESTIGATOR
Title
Given Name
Initial
Surname
Department
Institution
Address
City/Suburb
State
Telephone
Fax
Postcode
Email
OTHER PRINCIPAL INVESTIGATORS (including PEDIGREE collaborator)
Title
Given Name
Surname
Institution & email address
A
B
C
D
CONTACT PERSON FOR THIS APPLICATION IF NOT LEAD INVESTIGATOR
Title
Given Name
Surname
Role in this study
Department
Institution
Address
Address
City/Suburb
Telephone
State
Fax
Postcode
Email
Please return this form to Pedigree Co-ordinator, Cancer Epidemiology Centre, 615 St Kilda Road, Melbourne 3004
email: pedigree@cancervic.org.au
REQUEST AREA
Health 2020 Data
ABCFS Data
Health 2020 Biospecimens
ABCFS Biospecimens
Prostate Cancer Program Data
ACCFS Data
Prostate Cancer Program
Biospecimens
ACCFS Biospecimens
SYNOPSIS OF RESEARCH PLAN
Aims & Hypotheses (limit 700 characters)
Background (limit 2000 characters)
Please return this form to Pedigree Co-ordinator, Cancer Epidemiology Centre, 615 St Kilda Road, Melbourne 3004
email: pedigree@cancervic.org.au
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Version 3.4
EOI NO:
Date Received ___/____/_____
Electronic File Name:
Research Plan (limit 2000 characters)
Significance of project (limit 2000 characters)
RATIONALE FOR USING THE PEDIGREE RESOURCE
Please justify the use of Health 2020, the Prostate Program, ABCFS or ACCFS for this project.
Please return this form to Pedigree Co-ordinator, Cancer Epidemiology Centre, 615 St Kilda Road, Melbourne 3004
email: pedigree@cancervic.org.au
PROJECT REQUIREMENTS
a) Are existing data required?
Yes
No
b) Are existing biospecimens required?
Yes
No
c) Is subject contact required?
Yes
No
If Yes to (b), please detail type(s) of biospecimens and number required.
If yes to ( c ), please describe what is planned in this regard (e.g. numbers of participants, any
requirements of participants, measurements to be made on participant, duration of contact with
participant).
Is this request related to a previous request?
Yes
No
Is this request covered under an existing MOU or MTA?
Yes
No
Is this project HREC Approved?
Yes
No
If ‘Yes’, please supply details (HREC Approval Number, etc)
If ‘No’, please indicate the status of any application:
Have not applied
In progress
Date when HREC approval will cease:
ANTICIPATED TIMEFRAME
Commencement: _____/_____/_____
Completion: ______/______/______
Please return this form to Pedigree Co-ordinator, Cancer Epidemiology Centre, 615 St Kilda Road, Melbourne 3004
email: pedigree@cancervic.org.au
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