Joint UVic/VIHA 
Request for Amendment of an Approved Project		
Instructions: 
1.	Download this application and complete it on your computer. Hand written applications will not be accepted
2.	Submit one (1) original and one (1) copy of this completed, signed application with all attachments to:
Joint UVic-VIHA Subcommittee
VIHA Research Ethics Office
Room 304, Kenning Wing – Memorial Pavilion
Royal Jubilee Hospital
1952 Bay Street
Victoria, BC  V8R 1J8
3.	If you need assistance, contact the UVic HRE Assistant at (250) 472-4545 or ethics@uvic.ca
4.	Please note that incomplete applications cannot be processed and will be returned to the applicant.

Current Protocol Approval Number
Use the most recent Protocol No. for this project 	     	

Applicant Information
Principal Investigator	     	Department	     	
Phone	     	Fax	     	
Email	     	

Mail correspondence and approval to:	Department		Home	  Complete the address section below.	

Mailing address	     	

Position	Faculty		Staff		Master’s Student		Undergraduate Student		
					Ph.D. Student		Post-Doctoral		

Student Supervisor (if applicable)
Name	     	Email	     	

Co-Investigator(s) – Identify those collecting raw data. (Name, position [eg., Graduate Student] and department)
1.	     	Others (eg., Grad supervisor, committee)	
2.	     	1.	     	
3.	     	2.	     	
4.	     	3.	     	
5.	     	4.	     	

Title of Project
     

Request for Amendment 
 There will be changes to the protocol design or research materials
Attach details and rationale for the changes along with a brief synopsis of progress to date with an emphasis on any problems encountered during the conduct of the research. Submit this form with copies of any revised forms, tests, advertisements or questionnaires.	

Signatures
Signature of Student Supervisors indicates that they undertake to respect and abide by the statements of protection of confidentiality of data and anonymity agreed to by subjects/participants in the Letter of Informed Consent. When Chair/Director is the Principal Investigator, signature of Dean is required.
     
Signature of Principal Investigator	Signature of Supervisor	Signature of Chair/Director/Dean
Date:	Date:	Date:

________________________________
Signature of VIHA Administrator
Date:	

For UVic Ethics Use only: 	New Approval Number:	     	

     
	HREB Chair Signature	Approval Date:	Start Date:	End Date: