Section A: To be completed by Principal Investigator/Study Coordinator

Service Department:	Choose an item. Click or tap here to enter text.	Principal Investigator
ERM Number (5-6 digits):	RMH-	RMH Local Project No: (i.e., 20XX.YYY)
Short Project Title:
Is this a commercially sponsored clinical trial?	Yes No	Estimated number of participants:
Provide a brief description of service requested or reference the page/section in the protocol
Does the study involve using a genetically modified organism (GMO)?	Yes No
If Yes, has the service department been provided information and procedures for all GMO specific study requirements?	Yes No
Protocol No.:	Version:	Date:
I confirm that I have supplied the above service department with the most recent version of the protocol

Payment options – Select one option only

Charge to RMH cost centre:
Provide billing details:	Contact Name
Company Name
Billing Address
Name of Contact Requesting SOA:	Date:

Section B: To be completed by the Head or Nominee of the Service Department

Enter the date that this SOA was received by the Service Department. SOAs to be completed within 7 days for commercially sponsored clinical trials and within 14 days for all other projects.

I have reviewed and discussed the study protocol and applicable project documentation with the principal researcher or their delegate and confirm that this department:

Is able to do the investigations indicated with the present resources of the Department
Is unable to do the investigations within the present resources of the Department but would be willing to undertake them with financial assistance as specified below:
Is unable to undertake the investigations on the following grounds:
In signing this form, I declare that I am aware of the principles espoused in and the obligations imposed by the Australian Code for the Responsible Conduct of Research (2018) and its associated guide documents. In particular, I acknowledge the importance of the responsible management of research data.

Nominate Cost Centre for Credit

Service Department cost centre to be credited:

Signature – Head of Service Department or Delegate

Name (please print):	Click or tap here to enter text.	Position:	Click or tap here to enter text.
Signature (insert e- signature or signature block):	Date:	Click or tap to enter a date.