Request to Conduct Research

Interlake-Eastern RHA supports and promotes research that contributes to the advancement of health care. If you are affiliated with a research project and you are seeking engagement with our patients, clients residents or staff, please fill out the following form.

Request to Conduct Research

IDENTIFICATION

Project Title

Name

Are you still a student?

Yes

Address

Street Address City Postal Code

Phone (Work)

Phone (Home)

Email Address

FOR STUDENTS

Please Note: A letter from the course instructor / advisor identifying the student and outlining the purpose of the project is required.

School / University / College

Faculty / Department

Course research is required for?

Course Instructor / Advisor

FOR ALL NON-STUDENT RESEARCHERS

Organization

Position Held

Supervisor Name

Supervisor Job Title

RESEARCH PROJECT DETAILS

Ethical Approval obtained from

Date of Approval (dd-mm-yyyy)

Please Note: Interlake-Eastern RHA will not consider requests for research or information that do not have ethical approval from governing bodies. Please attach confirmation of ethics approval by the body governing this research.

Attach confirmation of Ethics approval

Accepted file types: pdf, doc, docx, txt, rtf, Max. file size: 5 MB.

If affiliated with the region, indicate site / facility

Short Description of Project

Attach Detailed Project Proposal

Accepted file types: pdf, doc, docx, txt, rtf, Max. file size: 5 MB.

Anticipated Start Date (dd-mm-yyyy)

Anticipated Completion Date (dd-mm-yyyy)

Will research results be published?

Yes

Indicate where and when, if known

Will the IERHA or the facility / program be identified in the report?

Yes

Please Note: You are required to submit a copy of the completed report to the region prior to publication.

What contact will you require with staff? With clients?

What requirements will you have in the region / facility / site?

This field is for validation purposes and should be left unchanged.