Study Proposal Application Form

ADEPT COMMITTEE

STUDY PROPOSAL APPLICATION FORM

Study or Project Title:
Study or Project Protocol Number:
Principal Investigator (PI):
PI Contact Address:
PI Email Address:
PI Telephone Number:
Submitting Organisation Details (for ADEPT fee payment):
Contact Address:
Email Address:
Telephone Number:
This is a…: (please tick as appropriate): / An REG-identified research priority
An Academic Study
A Commercial Study
Name of Study Funder: / Pearl diagnostics
Study or Project Steering Committee/Advisors: / Don D. Sin
Which Database is this Application for? / Optimum Patient Care Research Database
Clinical Practice Research Datalink
Hospital Episode Statistics Data
Date of Proposal Submission: / 18 July 2017
Name of Organisation: / OPRI
Type of Organisation / Academic Organisation
National Health Services
Research Service Provider
Government Organisation/Department
Charity Organisation/Non-Governmental Organisation
Pharmaceutical Industry
Other (please specify and explain below)
type of Study or Project: / Disease epidemiology
Drug effectiveness
Adverse drug reaction
Pharmaco-economic
Other (please specify and explain below)
Observational study
What is the Study or Project Intended for? / Publication
Conference
Exploratory research
Other (please specify and explain below)
Aim of the Study or Project:
Reviewer A
Reviewer B
Reviewer C
Describe the Study or Project Design:
Reviewer A
Reviewer B
Reviewer C
Describe the Potential Benefits of the Study or Project:
Reviewer A
Reviewer B
Reviewer C
Describe the Potential Risks of the Study or Project:
Reviewer A
Reviewer B
Reviewer C
Describe the Measures in Place for Data Security:
Reviewer A
Reviewer B
Reviewer C
Do you intend to provide access of data to any third parties? Please explain
Reviewer A
Reviewer B
Reviewer C
Is the study registered with ENCePP or other appropriate study registry? Provide details
Reviewer A
Reviewer B
Reviewer C
Does the study or project have Research Ethics Committee approval? Provide details
Reviewer A
Reviewer B
Reviewer C
General Comments
Reviewer A
Reviewer B
Reviewer C
Please send your study or project protocol in support of your application to:

ADEPT_Study Proposal Application Form_V2.1_24012016