Amendment Request Form

Please provide the information below and attach all relevant documents.

WAAHEC Reference:	Chief Investigator:	
Chief Investigator phone		
Chief Investigator organisation		
Chief Investigator email		
Project Title		
Approval date of project		

Extension of Time

Extension of time:	From:		To:		
*Please submit all documents (including updated revisions) and Amendments (Approvals).

Change of personnel
Additional researchers / co-investigators, including students
[Insert additional rows for additional investigators]
If the research recruits participants under 18 years of age, please provide the Working with Children (WWC) Check.

Addition of Investigator 	
Title and Name:		
Position:		
Address:		
Telephone:		
Email:		
Is the investigator of Aboriginal and/or Torres Strait Islander origin?		

Researchers no longer work on this project, including students 	
Researcher	Title, given name, and family name	Date no longer associated with project	
1				
2				

Provide details of the changes. Recommend dot points.	
Summarise all changes to the project:	

Provide reasons why the changes are necessary.	
Reasons for changes:	

What changes will be required to existing project documents (e.g. information and consent forms, etc.)
Attach copies of modified documents to this Amendment application.	
Impact on project documents:

		

Indicate any potential inconveniences, discomforts, harms or risks to participants.	
Potential impacts on participants:		

Indicate any additional actions or support that you need to provide as a result of the changes.	
Actions taken to manage risk:	

You cannot implement the requested changes before you receive formal approval from the WAAHEC	
Expected date of implementation:		

Please list if appropriate, e.g. do requested changes affect Privacy Act or Working With Children requirements and Guardianship Act?	
Potential legislative requirements:		

Location of research project implementation: 
Please provide name/s of town/s, city/cities, region/s or whether state-wide. 

	Kimberley		Great Southern 	
	Pilbara 		Wheatbelt	
	Murchison Gascoyne/Midwest		South West	
	Perth Metro 		National	
	Central Desert		State Wide 	
	Goldfields 			
	Other – Please list (Provide name/s of town/s, city/cities, ACCHS, communities, region/s)			

Please provide the project Narrative (Guidelines below)

	

Project Narrative Guidelines	
Communicates the public health relevance of the project to the public	
No more than 2-3 sentences	
Use plain language understandable by a general audience	
Describe how, in the short or long term, the research would contribute to: the fundamental knowledge about the nature and behaviour of living systems, and/or the application of that knowledge to enhance health, lengthen life, and reduce illness and disability.	
If the application is approved, the narrative will be available on the Ethics website	

It is important to accurately name the attachments as you want them to appear in the approval letter.
Attachment Type	Attachment Name (include version)	

		

		

Title and Name	Email	Is the investigator of Aboriginal and/or Torres Strait Islander origin?	

			

Signature of Chief Investigator	Date

Please submit this form and attachments to ethics@ahcwa.org