Project No:
Project Title:
Principal Investigator:Dept:

Type of Research

Clinical Trial  Drug/Device

Other Medical Intervention

Education/Supportive Care/Psycho-oncology Intervention

Phase: Pilot I I/II II II/III III Other:

CTN CTX N/A

Other Clinical Research

Laboratory/Basic Science Research

Please specify which tumour stream the project belongs to: ______

Does the project involve tissue collection? Yes No

Project Information
Is this project a:
Local Project (PeterMac only)
Victorian Project
National Project
International Project / For this project is the Principal Investigator the:
Local Lead
Victorian Lead
National Lead
International Lead
Peter Mac sites involved in the research project:
East Melbourne
Bendigo
Box Hill
Moorabbin
Sunshine / If this project will be running at any of the Peter Mac satellite sites, please contact the Office of Research at that site to discuss the implementation of the project.
Project Sponsor(Refers to regulatory sponsorship or overall coordination of project)
Commercial Name:
Cooperative/Collaborative Group Name:
Other External (eg University/Govt Agency) Name:
Peter Mac
 Investigator Initiated
 Other (please specify) ______
For all non-PeterMac sponsored projects please provide the following details for invoicing purposes:
Charge to:
(Company/Hospital Name etc.)
Contact Name:
(Name of person to whom the invoice is to be attentioned)
Phone Number:
Email address:
Company Address:

Peter Mac Supporting Departments

Indicate (please tick) which Peter Mac supporting services will be required to undertake this project:

Allied HealthSpecify service:

Biostatistics and Clinical Trials Centre (BaCT)

Clinical Trials Unit (Research Nurses/Study Coordinators)

Haematology

HIS (Medical Records)

Information Technology

Medical Oncology

Cancer Imaging Specify modality:

Nursing Services: Chemotherapy Day Unit (CDU)

Nursing Services: Medical Day Unit

Nursing Services: Otherinpatient unit/ward Specify service:

Nursing Services: Outpatient clinicSpecify clinic:

Peter Mac@Home

Pathology

Pharmacy

Physical Sciences

Radiation Oncology

Radiation Therapy Services

Research DivisionSpecify service:

Surgical Oncology

Tissue Bank

OtherSpecify:

1. You are required to notify supporting departments/clinical services and obtain their cooperation prior to submitting the project application. When submitting a Governance application, the Declarationsof Head of Supporting Departments (Declaration Section of theSite Specific Assessment, Part C) are submitted as part of that application.

2.These forms are required if the tests/procedures included in the project are standard care or additional to standard care.

3.For ALL Clinical Trials involving diagnostic or therapeutic agents, Declaration by Head of Supporting Department forms must be obtained, at a minimum, from CDU, Clinical Trials Unit, Pharmacy, Pathology, and Radiology, or an explanation provided as to why this is not necessary.

Divisional Review
Has this project proposal been reviewed and supported by your division? Yes No
Please provide details ______
______

I certify that this project proposal has undergone appropriate Directorate review processes and I support the conduct of this project at Peter Mac.

Name of Executive Director of Division: ______

Signature: Date:

Supplementary Peter Mac Submission Form Version April 2012Page 1 of 2