Standard Application Form For The Ethical Review Of Health-Related Research Studies, Which Are Not Clinical Trials Of Medicinal Products For Human Use As Defined In S.i. 190/2004 Page 15

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Version 5.5
May 2011
Office Use:
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REC Reference No:__________
F4.1 (b) If yes, for what purpose?
Answer
F4.1 (c) If yes, please state where samples will be sent?
Answer
F4.1 (d) If yes, please state if the samples leaving the institution of
origin will be anonymous, irreversibly anonymised, pseudonymised,
coded, identifiable etc?
Answer
E4.1 (e) If ‘coded’ please confirm who will retain the ‘key’ to re-
identify the samples?
Answer
F4.1 (f) Does a memorandum of understanding (or agreement /
contract) exist between the institution of origin and the institution to
which the samples will be sent? Please elaborate.
Answer
F5 GENETIC TESTING
F5.1 (a) Does this research study involve ‘genetic testing’?
Yes / No
F5.1 (b) If yes, please specify the nature of the genetic testing.
Answer
F6 COMMERCIAL VALUE
F6.1 (a) Will the human biological material in this research study or the
data derived from the analysis of the human biological material be
commercially valuable or is there the possibility that it will become
commercially valuable?
Yes / No
F6.1 (b) If yes, please elaborate.
Answer
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