Exploratory Data Analysis - Proposal

Instructions

Please submit this form if you would like to propose an exploratory analysis that Apellis should consider. All proposals will be reviewed by Apellis based on medical or scientific merit, unmet medical need, and availability of funds. Apellis reserves the right to pursue research concepts based on its sole discretion.

We may contact you if we have additional questions or would like to discuss your suggestion with you. Please allow at least four weeks for review of the proposal. The form below must be filled out in order for the EDA concept to be evaluated.

Please direct any questions to: medicalresearch@apellis.com

Requester Information

Name

Affiliated Institution

Street Address

City/Province

Country

Postal Code

Therapeutic Area

Indication

Clinical question(s)

What is/are the clinical question(s) data gap this analysis will address?

Study Information

Rationale

Why would you like the analysis conducted?

Preferred manner in which proposed analysis results may be shared:

Target timeline for completion of analysis

Include additional details about the EDA concept.

Acknowledgement

Print Name:

Date (dd/mm/yyyy):

Send me a copy of my responses

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