GST Tax Invoice
ABN 77 054 038 872
Research Office Credit Card Payment
Instructions
1. Fees are payable in FULL at the time of submitting documentation to the Research Office.
2. Only one Research Project payment may be submitted per Fee Payment Form.
3. Contact the Research Office (02 8382 4960) for a 'Fee Payment Reference number' (FPR#), required to complete this form.

* MANDATORY FIELDS
Research Office Fee Payment Reference (FPR#)*
(Mandatory for processing of payment contact the Research Office for FPR# to be issued - email: svhs.research@svha.org.au)
Study Investigator Name*
Full Project Title*
REGIS Identifiers or SVH File Reference Number
Company*
ABN*
Address*
Contact Name*
Email*
Phone Number*

St Vincent’s Hospital Sydney Research Office
Ethics & Governance Review of Clinical Trial Research Fee Schedule

For Initial Ethics Review Sponsor Amount (Ex-GST) Tick where applicable
New Ethics Application Commercial External Sponsor $6250       
  Non-Commercial External Sponsor $1000       
For the Ethics Review of Amendments Sponsor Amount (Ex-GST) Tick where applicable
General Amendments - Addition of site Commercial External Sponsor $1500       
  Non-Commercial External Sponsor $150       
Number of sites    
General Amendments - Addition of a Sub-Study Commercial External Sponsor $2500       
  Non-Commercial External Sponsor $500       
General Amendments - Major Amendment Commercial External Sponsor $1000       
  Non-Commercial External Sponsor $250       
General Amendments - Minor Amendment Commercial External Sponsor $500       
  Non-Commercial External Sponsor $150       
For the Initial Governance (SSA) Review Sponsor Amount (Ex-GST) Tick where applicable
New Site Application Commercial External Sponsor $4500       
  Non-Commercial External Sponsor $1000       
For the Governance Review of Site Amendments Sponsor Amount (Ex-GST) Tick where applicable
Non-standard contract review Commercial External Sponsor $2000       
  Non-Commercial External Sponsor $500       
General Amendments - Major Amendment Commercial External Sponsor $750       
  Non-Commercial External Sponsor $250       
General Amendments - Minor Amendment Commercial External Sponsor $325       
  Non-Commercial External Sponsor $100       

Your Privacy: St Vincent's Health Australia (SVHA) respects your privacy and complies with the National Privacy Principles. SVHA only collects that information needed to provide and communicate services to you. I authorise St Vincent's Hospital to deduct this amount from my credit card on receipt of this form.
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