(Appended Guides
Forms-1, Re: Article 5)

As the application form is reviewed by expertise in various fields, please
受理年月日
use simple and clear terminology.
For office use only
An experimental medical research on human beings受付番号
MUST ensure the fullyFor
officeuse contribution
only
informed consent of the participants and should clarify its
andforeseeable benefit.

Application Form for Joint Usage/Research Project
Date :

To:

dd/ mm /yyyy

(ext.

)

Director of the Medical Centre for Health Promotion and Sport Science,
Wakayama Medical University
Chief Applicant’s Information

Name (Chief Applicant):Institute/Department:

Position:

Address:

Tel:－－Fax:－－E-mail:1 ) Project MembersResearcher(s)List names of a chiefresearcher (applicant)and any otherco-researchers(co-applicants)

Joint Researcher(s)*The Researchers from theMedical Center for Health
Promotion and Sport Science,
Wakayama Medical
University

Technical Supporter(s)*The Staff from the Medical
Center for Health Promotion
and Sport Science,
Wakayama Medical
University

Institute/ Department/Position

Role(s)*Clarify a role of each applicant.
*The chief researcher is displayed on the Website.
*The detailed roles of each applicant should be written.

Role(s)*In the case of Joint Research, please fill this in.

Role(s)*In the case of Joint Usage, please fill this in.
*Please be aware that the staff joins the project as a technical supporter andhe/she can be regarded as a joint-researcher depending on his/her contribution
such as a data measurement or analysis.
12) Project Title*Please consider the title in terms of protection of intellectual property and other rights to avoid any
unexpected disadvantage.
*The chief researcher and the paper will be opened on the website.
3) Objectives (Describe in details the point to discover during Joint Usage/Research within 200 words)*Please clarify its background and aim(s).

4) Necessity of Joint Usage/Research・Contributions and Its Grounds

5) Process and Results of the past studies

6) Research Plan and Method*Describe the following points in details:-The experimental subjects and elements for study: choosing the appropriate classified subjects.
-An analysis method and the total research duration: confirming the appropriated method.
allocating enough time for the research-Appropriate precaution for the protections for human subjects.
*Indicate an alternative way in case of an unexpected process.

27) Facilities/Equipment in the Medical Centre to be used
*Choose and List the facilities and equipment to be used.
-Please refer to the list of facilities and equipment on http://www.kyoten.wakayama-med.reha.com*Indicate how the facilities and equipment chosen contribute the study, for examples,-What kind of data can be obtained-

How the obtained data enables to achieve the objectives8) Ethical Issues ( Animal Experiment/Ethics Approval from the Ethics Committee）*The ethics approval from either internal or external Ethics Committee can be accepted. As mentioned
above, the study should be completed by the end of March, 2016 and please receive the approval inadvance9) Grants and/or Published Papers in relation to the Joint Usage/Research (list all applicants, ifnecessary)*List the published papers in relation with the application (author, year, title and journal title in order)*In case of multi-authors, please underline the applicants.

[The Chief Applicant][Applicant’s supervisor/ Head of Department]

I agree that this study is conducted in association
with the Medical Centre for Health Promotion
and Sport Science, Wakayama MedicalUniversity.

I have read this application and agree to theresearch and, thus, hereby consent to apply asabove.

Position

Position

Printed namePrinted nameSignature

SignatureDate:

dd/ mm/ yyyy

Date:

dd/ mm/ yyyy3

Appendix.

Cost Itemized Statement (Estimated)
Expenses
1. Consumable
Goods

Totalyen

Items*Stationery and computer areexcluded.

Unit priceyen

Quantity

Priceyen*Any single item should notexceed over 100,000JPY.

2. Travel
expenses

Subtotal
Descriptions*Please indicate travel expenses of the travelers including
researcher(s) and experimental subject(s) at the time ofapplication submission.

yen
Price

yen

Subtotal

3. Others

Descriptions

Price*For examples,- the experimental subject- rental fee on facilities and equipment- the delivery of equipment

Subtotalyen*The grant is limited for mainly consumable goods and travel expenses.
*The pre-contact is necessary for the usage of grant and the usage is subject to the contents.
*The direct money transfer to each appropriate bank account is only allowed.

4