Western Health QA/Low Risk 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 (if applicable): E.g. 41234

HREC Reference Number: E.g. QA2020.123, LNR/19/ABC/123; HREC/41234/ABC-2018

Project title: Enter title

Principal Investigator	Contact person
Name:	Title, First & Surname	Name:	Title, First & Surname
Position:	Enter position title	Position:	Enter position title
Email:	Enter organisation email	Email:	Enter organisation email
Phone::	Enter contact number	Phone:	Enter contact number
Sponsor
Sponsor Name:	Name of Sponsor	Email:	Enter email address
Contact Person:	Name of contact person	Phone:	Enter contact number

Relevant Information for the Low Risk Ethics Panel
Study Type	Choose an item.
Name of Principal Investigator at WH site:	Title, First & Surname
WH sites this 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☐
Sponsorship/Funding type: *Research agreement may be required Commercial* ☐ Collaborative Group Sponsored* ☐ External Grants* ☐ Internally Sponsored ☐ Other ☐ Specify: Enter text
Budget (if funded):	Enter Amount
Anticipated duration of study:	Enter number Months
Anticipated Start Date:	Select date	Anticipated End Date:	Select date
Are there external researchers involved?	No ☐ Yes ☐ If yes, see Honorary Researcher Eligibility Flowchart
Please provide brief description of the research:
Click here to 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
1	WH QA LR Governance Cover Letter	N/A	Select date	Yes No	☐ ☐	Yes No	☐ ☐
2	Compliant Tax Invoice	N/A	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

Mandatory electronic file name convention:

To ensure the electronic copies submitted are easily identifiable, the format outlined below must be used for all electronic files. As shown in example below, include version numbers (if applicable) and dates in the file name.

Projects submitted with documents that do not follow the below naming convention/format will not be considered and will be returned via email to sender.

Convention: [Reference Number/ERM Project ID] [Document Name] [version number] [Date DDMMMYY]

E.g. 41234 Amendment Request Form 01Jan19