华南师范大学脑成像中心人类被试研究申请书V1.0华南师范大学脑成像中心人类被试研究申请书V1.0.doc

华南师范大学脑成像中心人类被试研究申请书V1.0 SCNU-BIC HUMAN SUBJECTS RESEARCH APPLICATION FORM 研究总负责人PRINCIPAL INVESTIGATOR 姓名，职称Name: First Name, Middle Initial, Last Name, Degree(s) 单位Institution: 华南师范大学 其他，请写明Other, specify 系/室Dept/Service: 组Division/Unit: 地址Address: 电话Tel: 传真Fax: 电子邮件E-Mail: 2. 课题题目PROJECT TITLE 声明CERTIFICATIONS 作为该研究负责人，我声明如下As Principal Investigator, I certify the followings: 我已经审阅过该协议并知道我将参与该研究I have reviewed this protocol and acknowledged my participation. 我已阅读并熟知华南师范大学脑成像中心涉及该研究的相关规章制度I have read and familiared with the SCNU-BIC Assurance governing this research. 我已经完成华南师大磁共振成像中心伦理与人体保护委员会所认可的与人体保护相关教育课程I have completed one of the human-subject protection education programs accepted by the IRB of SCNU-BIC. 我已经完成了进行该研究需要的相应培训 I have completed the applicable institutional credentialing processes required to conduct this research. 日期Date 研究负责人签字PRINCIPAL INVESTIGATOR (Sign date above) 我/我们在下面签名，以表明我/我们同意遵守与保护被试相关的政府和中心的条例，并承担相应责任。 I/we the undersigned accept responsibility for assuring adherence to government regulations, and institutional policies governing the protection of human subjects of research, including applicable institutional credentialing requirements. 日期Date 单位负责人（请填写姓名和单位并签名）DEPARTMENT CHAIR (Type name department and sign date above) 这些文件含有在华南师范大学脑成像中心开展研究的研究者或其资助者的机密和专有的信息。这些文件的传播必须符合华南师范大学脑成像中心的相应规定，外传须得到华南师范大学脑成像中心的许可。 These documents contain information that is confidential and proprietary to the participating SCNU-BIC or the study sponsor. Its distribution is restricted in accordance with SCNU-BIC policy and approval by the SCNU-BIC is required for outside distribution. 3. 合作者/参与研究人员资料CO-INVESTIGATORS/STUDY STAFF INFORMATION 在下面列出所有参与此项研究的合作者和研究人员，然后附上有每个人签名的个人申请书 List all co-investigators and staff participating in the below about the conduct of this study. Attach individual-specific co-investigator/study staff information pages with participating individual’s signature. 姓名