Research Application

Applicant Details

Organisation

Location (City)

Coordinator Name

Application Date

Coordinator Email

Coordinator Phone

Research Paper

Study Name

Study Short Code

Principal Investigator Email

Principal Investigator Phone

Funding Details

Sponsor Organisation

Sponsor Organisation Country

Organisation to Invoice

Invoicing - Preference

per patient / per week / per month / per year

Invoicing - Email

Invoicing - Phone

Imaging Requirements

Imaging Location

Auckland

Tauranga

Waikato

Wellington/Manawatu

Nelson

Canterbury

Otago/Southland

Ethics Approval (included with application)

Yes

No

please note that this is required prior to a referral form being sent out

Is your study deemed “company sponsored” by HDEC?

Yes

No

If yes, does your Principal Indemnity Insurance and/or Sponsor Insurance cover your third- party service providers, i.e., RHCNZ?

Yes

No

If no, we assume your study is eligible for ACC (or equivalent) cover.

Study Protocol (included with application)

Yes

No

Imaging Guidelines (included with application)

Yes

No

Data Transfer

Yes

No

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