Research Support Request Form

Thank you for contacting Active Health Clinic (AHC) for support with your research project.

We are excited to hear that you are supporting this community of people living with chronic and invisible health conditions.

Please complete all required fields and reach out to admin@activehealthclinic.com.au if you have any questions. If required, there is a "save and complete later" button at the end of the form.

Section 1 - General Details

Name *

Job Title *

Organisation *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Mobile Number

Office Phone Number

Email Address *

Section 2 - Project Details

What support are you looking for from AHC? *

Involvement in the projectPromotion of the project

Please state the title of the project *

Outline its aims and objectives *

Ultimately, what do you hope to achieve as a result of this project? *

What does success for this project look like to you? *

How would you like AHC to help you? *

How did you determine the need for this project? *

Do you have ethical approval? *

YesNoTBANot Needed

Name of ethics committee and approval number/ID *

Please provide more information *

What is your research methodology? *

Will data be collected as part of this project? *

YesNo

How will the data be collected? *

Is data anonymised? *

YesNoPseudonymised

How will you be inviting people to participate in your study? *

How will the data be analysed? *

How will the results be promoted/published? *

Proposed project start date *

Proposed project finish date *

This project is: *

FundedUnfunded

How is this project being funded? *

PrivateGovernment GrantOther

More information *

Will AHC receive any funding support for this project? *

Is there any supporting documentation to be attached? (eg. project outline/ survey questions /research proposal attached) *

YesNo

Upload documents *

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If uploading multiple documents, please select all of them before uploading. Uploading one at a time will replace the previous document

Section 4 - External Researcher and AHC Practitioner Meeting

Date of Meeting

AHC Clinician Name(s)

External Researcher Name(s)

Questions for the meeting:

Section 5 - Review Process

Reviewer Name

Reviewer role/specialism

Of benefit to the community

YesNo

Comments

AHC mission statement: We bring remarkable healthcare and community to those living with invisible illnesses

Further comments on how it aligns with AHC aims and values

Is this project ethical, credible, and fit for purpose?

YesNoTBAN/A

Further comments

What does success for this project look like to AHC?

Primary reviewer and secondary reviewer(s) approval conclusion

ApprovedRejected

Date of outcome *

Further comments on the conclusion

Approver Signature

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Date of review

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