form

First name

Last name

Organizational / Institution name

Street address

City

Zip code

Coutry selector

Title/Position within organization

Phone number

Email

Research/study title

Study objective/hypothesis

Principal investigator name (if different from above)

Same

Different

Proposed research start date (i.e. start of data collection)

Proposed research end date (i.e. completion of data collection and all study deliverables)

Number of sites planned

Number of subjects planned

Explanation of the study rationale and scientific novelty

Type of study

Prospective

Retrospective

Single or multi-arm

Single arm

Multi-arm

Randomization

Randomized

Non-randomized

Devices or treatments to be evaluated

Patient population

Endpoints evaluated

Treatment/assessment plan

Data collection plan / Quality assurance plan

Statistical analysis plan

Requested support

Device only

Other

Funding only

Both devices and funding

Are you receiving funding from any other source for this project? If yes, please specify in your attached documents.

Yes

No

Have any other requests been submitted to any other Getinge entities for support?

Yes

No

Please upload the following documents with your submission.
We recommend packaging all files into a single ZIP file for ease of upload.

Signed and dated Principal Investigator’s CV
Detailed Activity Budget (if monetary support is being requested)
Protocol synopsis and if available, protocol draft

Please upload the following documents with your submission.
We recommend packaging all files into a single ZIP file for ease of upload.

Signed and dated Principal Investigator’s CV
Detailed Activity Budget (if monetary support is being requested)
Protocol synopsis and if available, protocol draft

Upload Files

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