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   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
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  <div class="cstlDefaultStyle cstlNoSpacing" style="font-size: 6pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; position: relative; text-align: left;">
   &nbsp; 
   <div class="ISYS_DRAWING_DIV" style="position: absolute; left:-6px; top:-12px; z-index: -1; display:-moz-inline-stack; display:inline-block; zoom:1; *display:inline; border:0px; width:457px; height:29px; "> 
    <div class="ISYS_SIMPLE_SHAPE" style=" position: absolute; left:12px; top:0px; width:431px; height:27px; "> 
     <table class="ISYS_TEXTBOX" cellspacing="0" cellpadding="0" style="background-color: transparent; padding: 3px; margin: 0; text-align: left; white-space: normal; width:  100%; height: 100%; "> 
      <tbody>
       <tr style="margin: 0; padding: 0;">
        <td class="ISYS_TEXTOBJECT" style="width: 100%; vertical-align: top;"> 
         <div style="line-height: 100.00%; font-size: 18px; padding-bottom: 0px; text-align: left; vertical-align: top; ">
          <span style=" word-wrap: break-word; color: #000000; font-family: Arial; font-weight: bold; font-size: 18px; padding-left: 7px; padding-right: 7px; padding-top: 3px; ">NALHN </span>
          <span style=" word-wrap: break-word; color: #000000; font-family: Arial; font-weight: bold; font-size: 18px; ">LNR Ethics and Governance Application F</span>
          <span style=" word-wrap: break-word; color: #000000; font-family: Arial; font-weight: bold; font-size: 18px; ">orm</span>
         </div> 
         <div style="">
          <span style=" word-wrap: break-word; padding-bottom: 3px; padding-left: 7px; padding-right: 7px; "> <br /></span>
         </div> </td>
       </tr> 
      </tbody>
     </table> 
    </div> 
   </div> &nbsp;&nbsp;&nbsp;
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="padding-top: 8pt; text-indent: -30pt; padding-left: 4pt; padding-bottom: 1pt; font-size: 10pt; font-family: Arial; 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="text-indent: 0pt; padding-left: 4pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;font-weight:bold;">Instructions:</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: 0pt; padding-left: 4pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: 0pt; padding-left: 4pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Please note: responses must be typed into this form – </span>
   <span style="font-size:11pt;font-weight:bold;">do not</span>
   <span style="font-size:11pt;">&nbsp;write responses by hand. &nbsp;Invalid forms will be returned to the Researcher.</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: 0pt; padding-left: 4pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -16pt; padding-left: 20pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Complete this form, and get it signed by the Divisional Business Consultant and Divisional Director</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -16pt; padding-left: 20pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 2.&nbsp;&nbsp;&nbsp; Submit form and supporting documents to RGO for validity check </span>
   <a href="mailto:HealthNALHNRGO@sa.gov.au" target="_blank"><span class="cstlHyperlink" style="color: #0000ff; text-decoration: underline; font-size: 11pt; font-family: Calibri; text-align: left;">HealthNALHNRGO@sa.gov.au</span></a>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -10pt; padding-left: 14pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;RGO will confirm validity </span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -16pt; padding-left: 20pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Researcher to submit form and supporting documents to </span>
   <span style="font-size:11pt;font-weight:bold;">one</span>
   <span style="font-size:11pt;">&nbsp;of the Human Research Ethics Committee offices for expedited review::</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: 21pt; padding-left: 14pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">CALHN HREC: &nbsp;</span>
   <a href="mailto:CALHNResearchLNR@sa.gov.au" target="_blank"><span class="cstlHyperlink" style="color: #0000ff; text-decoration: underline; font-size: 11pt; font-family: Calibri; text-align: left;">CALHNResearchLNR@sa.gov.au</span></a>
   <span style="font-size:11pt;">&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: 21pt; padding-left: 14pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">SALHN HREC: &nbsp;</span>
   <a href="mailto:Health.SALHNOfficeforResearch@sa.gov.au" target="_blank"><span class="cstlHyperlink" style="color: #0000ff; text-decoration: underline; font-size: 11pt; font-family: Calibri; text-align: left;">Health.SALHNOfficeforResearch@sa.gov.au</span></a>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -10pt; padding-left: 14pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 5.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;HREC committee will approve ethics</span>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -10pt; padding-left: 14pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 6.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Researcher provides RGO with copy of HREC approval to </span>
   <a href="mailto:HealthNALHNRGO@sa.gov.au" target="_blank">HealthNALHNRGO@sa.gov.au</a>
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style="text-indent: -10pt; padding-left: 14pt; font-size: 10pt; padding-bottom: 1pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
   <span style="font-size:11pt;">Step 7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;RGO will provide authorization to commence the project</span>
  </div> 
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   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: auto; margin-left: 0; writing-mode:lr-tb;border-top:dotted 1px #000000;border-left:dotted 1px #000000;border-bottom:dotted 1px #000000;border-right:dotted 1px #000000;"> 
   <tbody>
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     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Project full title</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Term of the study</span>
      </div> </td> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 174.55pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Start date: </span>
      </div> </td> 
     <td colspan="2" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 179.10pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">End date: </span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Principal investigator</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Name: </span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Department: </span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Employer: </span>
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      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Work email: </span>
      </div> 
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       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Telephone: </span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Reviewing Human Research Ethics Committee (HREC)</span>
      </div> </td> 
     <td colspan="2" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 176.35pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Central Adelaide Local Health Network HREC</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-size: 10pt; padding-bottom: 4pt; font-family: Arial; text-align: left;">Southern Adelaide Clinical HREC</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style="padding-top: 0pt; padding-bottom: 4pt; font-size: 10pt; font-family: Arial; position: relative; text-align: left;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">SA Health HREC</span>
      </div> </td> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 177.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">Aboriginal Health HREC</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Women’s and Children’s Health Network HREC</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">Other:</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Other Committee approvals</span>
      </div> </td> 
     <td colspan="2" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 176.35pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Animal Ethics Committee</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Institutional Biosafety Committee</span>
      </div> </td> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 177.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Radiation Safety Report</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Other: </span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Type of application</span>
      </div> </td> 
     <td colspan="2" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 176.35pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Low Risk</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Negligible Risk</span>
      </div> </td> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 177.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">☐Access Request</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">Other:</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">SA Health sites involved in study</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">e.g. NALHN – LMH, MH, NCMHS, Watto Purunna</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Non SA Health sites involved in the study e.g. SAHMRI, University of Adelaide AHMS, UniSA HIB </span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Conflicts of interest</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;Yes </span>
       <span style="font-family:Arial;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">If yes, please provide details in the protocol</span>
      </div> </td> 
    </tr> 
    <tr style=" height:20.45pt; "> 
     <td rowspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Existing data </span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">(further details to be provided in the protocol)</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Will access to patient data be required in the study? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> </td> 
    </tr> 
    <tr style=" height:21.55pt; "> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Has participant consent been obtained? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> </td> 
    </tr> 
    <tr style=" height:37.25pt; "> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If access is required outside of your normal duties attach approval from person / department responsible for authorising access</span>
      </div> </td> 
    </tr> 
    <tr style=" height:56.50pt; "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">New Data collection </span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">(further details to be provided in the protocol)</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Arial; line-height: 1; position: relative; text-align: left;">
       <span class="cstlNormal" style="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; text-align: left;">Will there be collection of data? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlNormal" style="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; text-align: left;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlNormal" style="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; text-align: left;">&nbsp;No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Will participant consent be obtained? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes ☐ No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Will a databank be established? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;No </span>
      </div> </td> 
    </tr> 
    <tr style=" height:54.90pt; "> 
     <td rowspan="2" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Existing tissue/samples </span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">(further details to be provided in the protocol)</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Will access to tissue / samples be required in the study? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Are the tissue/samples held within your department? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Has participant consent been obtained? ☐ Yes ☐ No</span>
      </div> </td> 
    </tr> 
    <tr style=" height:72.80pt; "> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If access is required outside of your department attach approval from person /department responsible for access to tissue/sample e.g. manager of tissue bank</span>
      </div> </td> 
    </tr> 
    <tr style=" height:14.10pt; "> 
     <td rowspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">New sample collection </span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">(further details to be provided in the protocol)</span>
      </div> </td> 
     <td colspan="3" style=" border-bottom-color:#000000;border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; line-height: 1; font-family: Arial; position: relative; text-align: left;">
       <span class="cstlNormal" style="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; text-align: left;">Will there be collection of samples? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlNormal" style="font-family:Arial;font-size:10pt;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlNormal" style="font-family:Arial;font-size:10pt;">&nbsp;No</span>
      </div> </td> 
    </tr> 
    <tr style=" height:13.20pt; "> 
     <td colspan="3" style=" border-bottom:dotted 1px #000000;border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Will a tissue bank be established? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> </td> 
    </tr> 
    <tr style=" height:13.20pt; "> 
     <td colspan="3" style=" border-bottom:dotted 1px #000000;border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlNormal" style="font-family:Arial;font-size:10pt;">Will participant consent be obtained? </span>
       <span style="font-family:Arial;">☐</span>
       <span class="cstlNormal" style="font-family:Arial;font-size:10pt;">&nbsp;Yes </span>
       <span style="font-family:Arial;">☐</span>
       <span class="cstlNormal" style="font-family:Arial;font-size:10pt;">&nbsp;No</span>
      </div> </td> 
    </tr> 
    <tr style=" height:39.90pt; "> 
     <td style=" border-bottom:dotted 1px #000000;border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Peer review (e.g. grant application)</span>
      </div> </td> 
     <td colspan="3" style=" border-bottom:dotted 1px #000000;border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If yes, provide details</span>
      </div> </td> 
    </tr> 
    <tr style=" height:6.40pt; "> 
     <td rowspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Funding/Budget</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">To be discussed with the Divisional Business Consultant</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;font-weight:bold;">In-kind. </span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;color:#ff0000;font-weight:bold;">Provide details</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">: personnel and hours of support for NALHN staff.</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 cstlBodySAHealth" 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:6.20pt; "> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">Internal department funding</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">If yes, NALHN </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;/ University </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;/ SAHMRI </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;/ Other </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;color:#ff0000;font-weight:bold;">Provide details</span>
       <span style="font-family:Arial;color:#ff0000;">&nbsp;</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">of funding and cost centre for NALHN only</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 cstlBodySAHealth" 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:63.90pt; "> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; padding-bottom: 14pt; font-size: 11pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
       <span style="font-family:MS Gothic;">☐</span>
       <span class="cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; text-align: left;">&nbsp;External Funding</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">Grant</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">Company sponsored</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;">&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">Research Services</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;color:#ff0000;font-weight:bold;">Provide details</span>
       <span style="font-family:Arial;color:#ff0000;">&nbsp;</span>
       <span style="font-family:Arial;">of funding to be provided to or from NALHN <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 cstlBodySAHealth" 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:6.20pt; "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Agreements/Contracts</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">If funds are to be paid to or from NALHN, services or samples are being provided to another organisation, the research project involves intellectual property, an agreement must be in place. Agreements must be reviewed by the RGO and signed by the EDMS.</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Will there be an agreement associated with this study? </span>
       <span style="font-family:Arial;">☐ Yes ☐ No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">If yes please attach</span>
      </div> </td> 
    </tr> 
    <tr style=" height:105.35pt; "> 
     <td rowspan="2" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Non SA Health investigators</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Where the project is being conducted within NALHN or accessing NALHN participants, their tissue or data:</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Are all members of the project team employees of SA Health? </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;Yes </span>
       <span style="font-family:MS Gothic;">☐</span>
       <span style="font-family:Arial;">&nbsp;No</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If No, confirmation of Admin/HR/Laboratory Manager that non-SA Health investigators have approval to be on NALHN site(s) is required</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If not previously submitted to this Research Office please attach</span>
      </div> </td> 
    </tr> 
    <tr style=" height:42.35pt; "> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If the project involves team members who are not SA Health employees, confirmation of insurance and indemnity cover for the study by the non SA Health organisation is required</span>
      </div> </td> 
    </tr> 
    <tr style=" height:6.20pt; "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">CV/GCP</span>
      </div> </td> 
     <td colspan="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">A copy of a CV for all researchers / students involved in the study must be registered with the Research Office. &nbsp;Good Clinical Practice (GCP) certificates are recommended.</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If not previously submitted this to the Research Office </span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">please attach </span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 182.30pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Study Protocol (Mandatory)</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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="3" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 353.65pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Attach the Study Protocol and all additional documents (Patient Information and Consent Forms, questionnaires, recruitment flyers etc).</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="4" style=" border-left:dotted 1px #000000;border-right:dotted 1px #000000;border-top:dotted 1px #000000;border-bottom:dotted 1px #000000;width: 535.95pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Additional information to assist with the review:</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; 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 cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; 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=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;line-height: 1; ">
       <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;line-height: 1; ">
       <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;line-height: 1; ">
       <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;line-height: 1; ">
       <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;line-height: 1; ">
       <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;line-height: 1; ">
       <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
   <span style="font-weight:bold;">&nbsp;</span> 
   <br />
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-weight:bold;">RESEARCHERS</span>
   <span style="font-weight:bold;">:</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   Project title: 
  </div> 
  <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 cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
   Declaration by all research personnel involved in the study at this site
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   I/we certify that:
  </div> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>1.&nbsp;All information in this form is truthful and as complete as possible.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>2.&nbsp;I/we have had access to and read the <span style="font-style:italic;">NHMRC National Statement on Ethical Conduct in Human Research 2007</span>&nbsp;(National Statement) and the <span style="font-style:italic;">Australian Code for the Responsible Conduct of Research 2018</span>&nbsp;(the Code).</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>3.&nbsp;The research will be conducted in accordance with all ethical and research governance arrangements of the organisations involved. </li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>4.&nbsp;I/we have no conflicts of interest or have disclosed any conflicts of interest to the ethics review committee and NALHN Research Office and will manage them in accordance with the National Statement and the Code.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>5.&nbsp;I/we will maintain the confidentiality, integrity, privacy and security of information in accordance with the <span style="font-style:italic;">SA Health Code of Fair Information Practice 2004</span>&nbsp;and <span style="font-style:italic;">Australian Privacy Principles 2014</span>.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>6.&nbsp;I/we have consulted any relevant legislation and regulations, and the project will be conducted in accordance with these.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>7.&nbsp;I/we will only commence this research project after obtaining ethics approval and governance authorisation.</li> 
  </ol> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: 524.65pt; margin-left: 0; 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=" "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 119.95pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Name</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;width: 121.85pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Role</span>
      </div> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">e.g. PI/ student/ supervisor </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;width: 112.05pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Employer/Affiliation</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;width: 170.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Signature</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 119.95pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</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;width: 121.85pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</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;width: 112.05pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 170.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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=" "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 119.95pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</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;width: 121.85pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">&nbsp;</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;width: 112.05pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 170.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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=" "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 119.95pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 121.85pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 112.05pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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 style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 170.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   (insert&nbsp;additional lines if necessary)
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-weight:bold;">Submission Check list</span>:
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Protocol
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>:Participant&nbsp;Information Sheet and Consent Form
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Data collection tool 
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Questionnaires
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Recruitment Script
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Interview Focus Group guide
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Advertising
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Divisional Business Consultant approval
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Divisional Director approval
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Supporting email from Medical Records (if study is accessing patient records)
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;CV and GCP attached for all investigators
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Insurance certificates of currency attached for all non-SA Health employees
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Confidentiality deed attached for all non-SA Health employees/students
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Police checks attached for all non-SA Health employees/students (on site or accessing identifiable data)
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Confirmation of Student IP Deed poll for HDR students
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>&nbsp;Copies of all agreements (grant contracts, collaboration agreements, material transfer agreements, etc)
  </div> 
  <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> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
   &nbsp; 
   <br />
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-weight:bold;">DIVISIONAL APPROVAL</span>
   <span style="font-weight:bold;">:</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> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   Project title: 
  </div> 
  <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;padding-bottom:0pt;line-height: 1; ">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-weight:bold;">Declaration by the NALHN Divisional Business Consultant</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   I certify that the site Principal Investigator has discussed the research project named above with me, and I am satisfied that the financial impacts on the Division have been adequately addressed.
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: 503.50pt; margin-left: 0; 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:17.80pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Name of Divisional Business Consultant</span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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:28.50pt; "> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 368.50pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Signature </span>
      </div> </td> 
     <td style=" border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;width: 135pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Date</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   Supporting e-mails will be accepted in lieu of signatures
  </div> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;line-height: 1; ">
   <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;line-height: 1; ">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-weight:bold;">Declaration by the NALHN Divisional Director</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-style:italic;">This declaration must be completed by </span>
   <span style="font-weight:bold;font-style:italic;">all NALHN </span>
   <span style="font-style:italic;">Divisional Directors (or facility, location or service) involved in supporting the project. Divisional Nursing Director approval is also required for projects involving nursing staff. Attach a separate declaration for the head of </span>
   <span style="font-weight:bold;font-style:italic;">each</span>
   <span style="font-style:italic;">&nbsp;department involved in the project at this site.</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-style:italic;">Where the principal investigator for the study is also the head of department, certification must be sought from the person to whom the head of department is responsible. Investigators must not approve their own research on behalf of the department.</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>1.&nbsp;I certify that I have read the&nbsp;project application named above.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>2.&nbsp;I certify that I have discussed this project and the resource implications for this department with the principal investigator.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>3.&nbsp;I certify that the principal investigator and other investigators involved in the project have the necessary skills, training and experience to undertake their role, and where necessary, appropriate training and supervision has been arranged.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>4.&nbsp;I certify that there are suitable and adequate facilities and resources for the project to be conducted at this site as proposed, and they are available for the duration of the project.</li> 
  </ol> 
  <ol class="cstlDefaultStyle cstlBodySAHealth" style="position: relative; padding-top:0pt;text-align:left;padding-left:10pt;text-indent:0pt;list-style-type:none;"> 
   <li>5.&nbsp;I certify that the research project has been costed appropriately and there are sufficient funds to cover the costs of conducting research at the site.</li> 
  </ol> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   My signature indicates that I support this project being carried out using the required resources, based on the information provided by the principal investigator.
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: 503.50pt; margin-left: 0; 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:21.55pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Name of Division</span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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:17.80pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Name of Divisional Director</span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" 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:28.50pt; "> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 368.50pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Signature </span>
      </div> </td> 
     <td style=" border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;width: 135pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Date</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlBodySAHealth" 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;padding-bottom:0pt;padding-top:0pt;">
   &nbsp; 
   <br />
  </div> 
  <div class="cstlDefaultStyle cstlHeading4" style="padding-top: 4pt; color: #000000; font-weight: bold; text-decoration: underline; font-size: 11pt; padding-bottom: 14pt; font-family: Arial; line-height: 1.15; position: relative; text-align: left;">
   RESEARCH OFFICE USE ONLY
  </div> 
  <div class="cstlDefaultStyle cstlHeading4" 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-weight:bold;">Declaration by Research Office</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   Project title
   <span style="font-weight:bold;">: </span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   Our Reference
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   HREC: 
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   SSA: 
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   This application has been reviewed and is:
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>Supported
  </div> 
  <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;">
   <span style="font-family:MS Gothic;">☐</span>Not Supported
  </div> 
  <div class="cstlDefaultStyle cstlNoSpacing" style="font-size: 6pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <div class="cstlDefaultStyle cstlNoSpacing" style="font-size: 6pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: 503.50pt; margin-left: 0; 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:21.55pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Name </span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; 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> </td> 
    </tr> 
    <tr style=" height:22.45pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Position</span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; 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> </td> 
    </tr> 
    <tr style=" height:28.50pt; "> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 368.50pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Signature </span>
      </div> </td> 
     <td style=" border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;width: 135pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">Date </span>
      </div> </td> 
    </tr> 
    <tr style=" height:28.50pt; "> 
     <td colspan="3" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 503.50pt; "> 
      <div class="cstlDefaultStyle cstlBodySAHealth" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span class="cstlBodySAHealth" style="font-family:Arial;font-size:10pt;">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> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-weight:bold;">Final Authorisation</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodyText" style="font-size: 12pt; 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> 
  <div class="cstlDefaultStyle cstlBodyText" style="font-size: 12pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Arial;font-size:10pt;">Noting the endorsement provided above, I hereby recommend this project is:</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodyText" style="font-size: 12pt; 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> 
  <div class="cstlDefaultStyle cstlBodyText" style="font-size: 12pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:MS Gothic;font-size:10pt;">☐</span>
   <span style="font-family:Arial;font-size:10pt;">Authorised</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodyText" style="font-size: 12pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:MS Gothic;font-size:10pt;">☐</span>
   <span style="font-family:Arial;font-size:10pt;">Not Authorised</span>
  </div> 
  <div class="cstlDefaultStyle cstlBodyText" style="font-size: 12pt; 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> 
  <table cellspacing="0" style="width: 503.50pt; margin-left: 0; 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:21.55pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">Name </span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; 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> </td> 
    </tr> 
    <tr style=" height:22.45pt; "> 
     <td style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 141.70pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">Position</span>
      </div> </td> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 361.80pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; 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> </td> 
    </tr> 
    <tr style=" height:28.50pt; "> 
     <td colspan="2" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 368.50pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">Signature </span>
      </div> </td> 
     <td style=" border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;width: 135pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">Date</span>
      </div> </td> 
    </tr> 
    <tr style=" height:28.50pt; "> 
     <td colspan="3" style=" border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 503.50pt; "> 
      <div class="cstlDefaultStyle cstlBodyText" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 12pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">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> 
  <p style="margin-bottom:5px;background-color:#E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Arial; line-height: 1; position: relative; text-align: left;">
   &nbsp;
  </div> 
  <div class="cstlDefaultStyle cstlHeader" style="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; 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="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; line-height: 1; position: relative; text-align: left;">
   Page 
   <span style="font-weight:bold;">&nbsp;</span>
   <span style="font-weight:bold;">&nbsp;</span>
   <span style="font-weight:bold;">&nbsp;</span>
   <span style="font-weight:bold;">4</span>&nbsp;of 
   <span style="font-weight:bold;">&nbsp;</span>
   <span style="font-weight:bold;">&nbsp;</span>
   <span style="font-weight:bold;">&nbsp;</span>
   <span style="font-weight:bold;">6</span>
   <span style="font-weight:bold;">&nbsp;&nbsp;(V1.2 May 2020)</span>
  </div> 
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Arial; 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>  
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