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   <li><span style="font-family:Arial;font-size:10pt;">1.&nbsp;Please DO NOT submit a cover letter with this form.</span></li> 
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   <li><span style="font-family:Arial;font-size:10pt;">2.&nbsp;This form should be filled in electronically and submitted with the original SSA</span></li> 
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   <li><span style="font-family:Arial;font-size:10pt;">3.&nbsp;Incomplete submissions may be rejected or result in delayed review.</span></li> 
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   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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       <span style="font-family:Arial;font-weight:bold;">Site:</span>
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       <span style="font-family:Arial;font-weight:bold;">HREC Ref:</span>
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       <span style="font-family:Arial;font-weight:bold;">Study Title:</span>
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       <span style="font-family:Arial;font-size:11pt;font-weight:bold;">RESEARCH CO-ORDINATOR PERSONNEL</span>
      </div> </td> 
    </tr> 
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       <span style="font-family:Arial;font-weight:bold;">Name of research co-ordinator: </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-weight:bold;">     </span>
      </div> </td> 
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     <td colspan="8" style=" border-bottom-color:#000000;border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;background-color:#f3f3f3; width: 561.50pt; "> 
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       <span style="font-family:Arial;font-weight:bold;">Research responsibilities at the site (list all tasks as per delegation log):</span>
      </div> 
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       <span style="font-family:Arial;font-weight:bold;">*This section must be completed </span>
      </div> </td> 
    </tr> 
    <tr style=" height:19.35pt; "> 
     <td colspan="3" style=" border-top-color:#000000;border-right-color:#000000;border-left:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#f3f3f3; width: 281.35pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Obtain informed consent &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Subject selection/recruitment&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Confirm eligibility (review inclusion/exclusion criteria) &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Obtain medical history (source documents) &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Perform physical exam&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Conduct study visit procedure as outlined in the protocol&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Make study related medical decisions&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:9pt;">Assess AEs/SAEs&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Dispense study drug&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Perform drug accountability&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Study drug storage and temperature monitoring&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="5" style=" border-top-color:#000000;border-left-color:#000000;border-right:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#f3f3f3; width: 280.15pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Sample collection&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Sample processing and/or shipment&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Evaluate study related test results&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Use IWRS/IVRS&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Make entries/corrections on CRFs&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Sign off CRF&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Maintain essential documents&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Perform study-related assessments as per protocol &nbsp;&nbsp;&nbsp;☐</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Other (specify): </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Other (specify): </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Other (specify): </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">     </span>
      </div> </td> 
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      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Are you currently employed by the site for the purpose of this research project?</span>
       <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Yes ☐</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;No ☐</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;"> <br /></span>
       <span style="font-family:Arial;font-weight:bold;font-style:italic;">If no, evidence of Insurance/Indemnity from your employer must be provided</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">If not employed by the site, list the external organisation and department at organisation: </span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">If not employed by the site, is DCSI clearance required?&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;">Yes ☐</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;No ☐</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <a href="https://screening.dcsi.sa.gov.au/screening-process/types-of-screening" target="_blank"><span class="cstlHyperlink" style="color: #0000ff; font-weight: bold; text-decoration: underline; font-size: 11pt; font-family: Calibri; text-align: left;">https://screening.dcsi.sa.gov.au/screening-process/types-of-screening</span></a>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:19.35pt; "> 
     <td colspan="8" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#a6a6a6; width: 561.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:11pt;font-weight:bold;">RESEARCH CO-ORDINATOR DECLARATION</span>
      </div> </td> 
    </tr> 
    <tr style=" height:19.35pt; "> 
     <td colspan="8" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;width: 561.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-style:italic;">I declare that I have read the study protocol &amp; understand my obligations and responsibilities, and that site I will not conduct any study related activities until I have been granted authorisation by the site Research Governance Office.</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Signature: </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> <a name="bm_Text33"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Date: </span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">&nbsp;</span>
       <span style="font-family:Arial;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:19.35pt; "> 
     <td colspan="8" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#a6a6a6; width: 561.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:11pt;font-weight:bold;">PRINCIPAL INVESTIGATOR DECLARATION</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:19.35pt; "> 
     <td colspan="8" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;width: 561.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-style:italic;">I confirm that the study co-ordinator named on this form is appropriately qualified and will be trained in the administration of the approved study protocol.</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> <a name="bm_Text34"></a>
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Name: &nbsp;</span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-weight:bold;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Signature: </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Date: </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-weight:bold;">     </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:29.95pt; "> 
     <td colspan="8" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#a6a6a6; width: 561.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:14pt;font-weight:bold;">OFFICE USE ONLY</span>
      </div> </td> 
    </tr> 
    <tr style=" height:29.95pt; "> 
     <td colspan="2" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#f3f3f3; width: 256.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:right;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Received &amp; Authorised </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:right;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">by Research Governance Officer (Name):</span>
      </div> </td> 
     <td colspan="6" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;width: 304.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:31.80pt; "> 
     <td colspan="2" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#f3f3f3; width: 256.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:right;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Signature:</span>
      </div> </td> 
     <td colspan="3" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;width: 137.65pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#f3f3f3; width: 72.40pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:right;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Date:</span>
      </div> </td> 
     <td style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;width: 94.55pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:47.60pt; "> 
     <td colspan="8" style=" border-left:solid 2px #000000;border-right:solid 2px #000000;border-top:solid 2px #000000;border-bottom:solid 2px #000000;background-color:#f3f3f3; width: 561.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">RGO Comments:</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="margin-bottom:5px;background-color:#E7EAEF;">&nbsp;</p>
  <table cellspacing="0" style="width: 552.85pt; margin-left: -8.80pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" height:41.75pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f3f3f3; width: 273.75pt; "> 
      <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Times New Roman;font-size:14pt;font-weight:bold;">SSA Attachment: </span>
      </div> 
      <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Times New Roman;font-size:14pt;font-weight:bold;">Research Co-ordinator Authorisation Form </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f3f3f3; width: 279.10pt; "> 
      <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       &nbsp;
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlHeader" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlFooter" style="text-indent: -14pt; padding-left: 0pt; font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Arial;font-size:8pt;">SSA Attachment: Research Co-ordinator Authorisation Form v. 19.01 Jan 2019&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Page </span>
   <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
   <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
   <span style="font-family:Arial;font-size:8pt;">1</span>
   <span style="font-family:Arial;font-size:8pt;">&nbsp;of 2</span>
  </div> 
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   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>  
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