Tip:  Please read through the questions before starting to ensure you have all the
relevant information to hand as this form cannot be saved for completion at a later date.

1. If this project has an external (non-WDHB) Principal Investigator, enter details here: If none -->Q2
   
   Title Choose one... Assoc Prof Dr Miss Mr Mrs Ms Prof Other (specify with name) 
   External P.I's Full Name:
   
   External P. I's organisation:
   
   External P. I's email address:
   
   External P. I's mobile phone:
   

2. Enter name of Waitemata DHB Principal Investigator:
   If none-->Q3
   
   Title Choose one... Assoc Prof Dr Miss Mr Mrs Ms Prof Other (specify with name) 
   Full Name:  

3. Enter details for any other Waitemata DHB contacts for this project:
   (Include their role e.g. Co-investigator, Research Nurse, Supervisor):
   If none-->Q4
   

4. Phone Number(s) WDHB Principal Investigator: (named in Q2)              

5. Phone Number(s) Other WDHB Contacts: (named in Q3)           

6. Please nominate the primary contact person (from those named in Q1-Q3) for correspondence regarding this project: 
   WDHB Approval forms will be emailed to the primary contact.
    

7. Name of host Waitemata DHB department(s) & physical location: 

8. Project Title (or Provisional Title)  

9. Type of project?         Choose one... Audit or evalution Clinical trial Observational Research Other

10. Expected project start date?   

11. Anticipated project end date?
     

12. Is this a multi-centre project?     No -->Q13   Yes 
    .... If Yes, is WDHB the lead site  No                 Yes
     

13. Will ethics approval be sought?   No -->Q14   Yes
    …If Yes, will this be:
    Full National Application Form (NAF)     
    Expedited review
    Non-HDEC review (e.g. university ethics committee)
    Not sure
    
    Please refer to the guidelines at http://www.ethicscommittees.health.govt.nz/

14. Will the project involve fund sources external to WDHB?   No -->Q15    Yes
    
    .... If Yes, enter name of fund source/ organisation providing funding:   
    
    .... Is WDHB a signatory of the funding contract?
    No     Yes

15. Briefly outline your project: (what is the key objective, e.g. to compare treatment regimes, evaluate service provision etc)
     

16. Enter (as a list) some keywords for this project: (i.e. words that might be used in a 'search' for this project. These may or may not be words already in the project title)
     

17. Current status of project: (briefly describe what stage this project is at e.g. planning, literature search, awaiting ethical approval etc. Also use this space for any further queries
    or to request assistance)