杭州师范大学认知与脑疾病研究中心磁共振研究伦理审查申请书.doc

研究总负责人PRINCIPAL INVESTIGATOR 姓名： Name: 学位或者职称： Degree(s): 单位： Institution: 地址： Address: 邮编post code: 电子邮件E-Mail: 电话Tel: 传真Fax: 2. 课题题目PROJECT TITLE 3. 研究信息PROTOCOL INFORMATION 3.1. 被试数目Number Of Subjects: 在杭州师范大学认知与脑疾病研究中心测试的被试数 Target enrollment at CCBD (#): 整个实验测试的被试数Target enrollment study-wide (#): 实验预计机时Predicted scan time（h）： (国内/国际NATIONAL/INTERNATIONAL) 被试将在这些地方招募 Subjects will be enrolled at these sites: 3.2. 被试类型（在相应项目上划钩）Types Of Subjects: (Check All That Apply) 成人ADULT 未成年人PEDIATRIC 18-64岁Adults (18-64) 新生儿/婴儿Newborns/Infants 健康志愿者Healthy Volunteers 65岁（含）以上Adults (65+) 儿童（2-12岁）Children (2-12) 判断力受损者: 如精神状态异常，脑损伤等Decisionally Impaired, e.g., mental abnormal state, brain injury, etc. 青少年（13-18岁）Adolescents (13-18) 躯体障碍，如脊髓受损Physically Disabled, e.g., spinal cord injury 注意：填写以儿童为被试进行研究相关问题的表格Complete separate form addressing issues related to the enrollment of children in research 孕妇Pregnant Women 其他，请说明Other, specify: 这些文件含有在杭州师范大学认知与脑疾病研究中心开展研究的研究者或其资助者的机密和专有的信息。这些文件的散发必须符合杭州师范大学认知与脑疾病研究中心的相应规定，其外传须得到中心的许可。 These documents contain information that is confidential and proprietary to the participating CCBD or the study sponsor. Its distribution is restricted in accordance with CCBD policy and approval by the CCBD is required for outside distribution. 3.3. 被试来源（在相应项目上划钩）Source Of Subjects: (check all that apply) 基层医生/专科医生Primary Physician/Physician Specialist 报纸/电台/电视广告Newspaper/Radio/Television Advertising 急诊室Emergency Room 学校内张贴Postings within School(s) 住院病人Inpatients 电子邮件E-Mail Announcements 人口调查/公共记录/商业邮件列表Census/Public Records/Commercial Mail Lists 因特网站Internet Sites 医疗记录/病人数据库Medical Records/Patient Databases 其他，在小结中解释Other, explain in protocol summary 注意：所有用于招募被试的广告和信件文本应提交委员会审议 NOTE: The text of all advertisements and letters used to recruit subjects must be submitted for IRB approval. 3.4. 被试知情同意书手续（在相应项目上划钩）Consent Procedures: (check all that apply) 符合政府规定的书面的被试知情同意书 WRITTEN Consent Waive