HSG Investigator-Initiated Clinical Research Formal Proposal

HSG Investigator-Initiated Clinical Research Formal Proposal

Before filling out this proposal form, please read through it and make sure you have all required elements ready to submit at one time. This application is not a “save as you go” process, so please be sure you have your necessary documents ready to upload when you complete your application.

Name*

Please enter your full name.

Date*

Email*

Please enter your email address

Phone*

Please enter your phone number

Applicant's Institution*

Institution/Organization Address*

Title of Proposal*

Title of Proposal and acronym, if available

Is this a resubmission?*

Yes

Clinical Phase

(if applicable)

HSG Investigators and Coordinators*

HSG Sites

(if applicable)

Please upload the following files*

Protocol Synopsis
Cover Letter
Biosketch, CV, Resume, or equivalent for all PI(s)/Co-PI(s) on project
Other supporting or related material, if applicable

Drag and drop files here or

Estimated Budget*

Please enter costs as applicable:

Access to Study Database*

Do you assure unrestricted access to the study database (if applicable)?

Right to Publish*

Do you assure unrestricted right to publish all results?

Steering Committee*

Is a study Steering Committee in place, with appropriate expertise? If not, is there an adequate plan for identifying a Steering Committee?

Please provide details:

Project Management and Study Coordination*

Is there appropriate provision for project management and study coordination?

Please provide details:

Data Management and Biostatistical Support*

Is there appropriate data management and biostatistical support?

Please provide details:

Vendors Agreements/Licensing

Are other vendors required? (For example: drug supply, devices, PRO tools, assessments that require licensing) If so please provide details:

Human Subject Concerns*

Are there human subject concerns in your proposal?

Please provide details:

Conflict of Interest*

Does your proposal pose any conflict-of-interest or potential conflict-of-interest?

Please explain:

Data Sharing*

Will you agree to provide to the HSG any new data obtained and a copy of your analysis?

Other Funding*

Have you secured or applied for other funding for this project (or a similar project)?

Please provide details:

Intellectual Property*

What Intellectual Property (IP) could result from this project (if any)?

I understand and agree that any Intellectual Property (IP) developed by an HSG Committee or Working Group and/or with HSG resources will be reviewed and discussed on a case-by-case basis to determine acknowledgment and ownership rights.*

Send me a copy of my responses

Privacy Notice|Report Abuse