(Please Insert today’s date)

Chairperson

Human Research Ethics Committee (HREC)

Calvary Health Care Bruce

PO Box 254

Jamison Centre

ACT 2614

Dear Chairperson,

We would like to undertake a clinical audit of medical records at Calvary Health Care ACT (Public) by (type of student) students from the (name ofuniversity)for research purposes.

We believe this work involves negligible risk for patients and can be exempt from ethical review under Sections 2.1.7 and 5.1.22 of the National Statement on Ethical Conduct in Human Research 2007. This project involves a retrospective audit of patient medical records permitted under Section 95 of the Privacy Act 1988.

Findings from this project may be published or presented at a conference, and so in complying with the CHCACT Publications, Abstracts and Presentations Policy wewish to inform Calvary Health Care ACT (Public) HREC of this prospect.

We are familiar with the CHCACT Guidelines for Research Practice, and we understand that a final report as per the National Statement, and a copy of the resulting university assignment is required to be submitted to the HREC on completion of this project.

Please find a description and details of the project below. (Please fully complete this form)

Student/s name and contact details / Name:
Address:
Phone:
Mobile:
Calvary Mentor/s name and details / Name:
Address:
Phone:
Mobile:
Title of the proposed study
Site/s where you intend carrying out this study / Site 1:
Site 2:
Site 3:
Site 4:
Description of the project / Description:
The Aim of this Study
How you intend to undertake the project?
Who will be included in the target research group?
How many participants are expected to be included in this study?
Do you envisage any harm/risks to come to patients?
How do you intend to minimize any harms/risks?
How will you control the privacy of the patients?
How will the information be stored during analysis and after completion of the audit? / During Analysis of the Study:
After Completion of the Study:
Where do you intend to publish the results?
How do you intend to disseminate the results to the Calvary clinicians?
What is the Anticipated Start date of your study? / Day/Month/Year
/ /
What is the Anticipated End date of your study? / Day/Month/Year
/ /
Do you have funding for this study?
(Please provide evidence of this)
How much is the funding? / $
Who is the Funding Body?
Do you intend to use Calvary Health Care Staff or Equipment? If Yes – you will need to complete an Estimate of Costs Formto accompany this application, which can be downloaded from the ethics website.
If you do not intend to use Calvary Health Care Staff or Equipment, what other resources does your study include?
Name any other Ethics committee/sapproached for approval of this project
(Please provide evidence of this)
What was the result from the other ethics committees approached for your study?
(Please provide evidence of this)

The student/s involved in the research is/are aware of their responsibility for confidentiality in respect to patients’ medical records.

Data used (please tick appropriate box)

□ De-identified

□Identified

□No identifying labels will be provided in any published or presented material.

Yours sincerely,

Signatures

Supervisor’sName:

Supervisor’s Signature:Date:

Qualifications:

Contact Details:

Student’s Name:

Student’s Signature:Date:

1