Application Form

01.	Scientific Title of Trial		[?]
02.	Public Title of Trial (in lay language)		[?]
03.	Acronym, if any		[?]
04.	Brief title, if any		[?]
05.	Any other number(s) assigned to the trial and issuing authority, if any (eg. sponsor, other trial registry)
06.	Disease or Health Condition(s) studied		[?]
07.	What is the research question being addressed?		[?]
08.	Study design		[?]
09.	Intervention(s) planned		[?]
10.	Inclusion criteria		[?]
11.	Exclusion criteria		[?]
12.	Target number / sample size		[?]
13.	Primary outcome(s)		Outcome Measure(s) [?]
			Time of assessment [?]
14.	Secondary outcome(s)		Outcome Measure(s) [?]
			Time of assessment [?]
15.	Countries of recruitment		Aruba Afghanistan Angola Anguilla Åland Islands Algeria Albania Andorra Netherlands Antilles United Arab Emirates Argentina Armenia American Samoa Antarctica Antigua and Barbuda Australia Austria Azerbaijan Burundi Belgium Benin Burkina Faso Bangladesh Bulgaria Bahrain Bahamas Bosnia and Herzegovina Belarus Belize Bermuda Bolivia British Indian Ocean Territory Brazil Barbados Brunei Darussalam Bhutan Bouvet Island Botswana Central African Republic Canada Cocos Islands Chile China Croatia Cambodia Côte d'Ivoire Cameroon Congo Cook Islands Colombia Comoros Cape Verde Costa Rica Chad Cuba Christmas Island Cayman Islands Cyprus Czech Republic Djibouti Dominica Denmark Dominican Republic Ecuador Egypt Eritrea Equatorial Guinea Estonia Ethiopia Finland French Polynesia French Southern Territories Fiji Falkland Islands France Faroe Islands Gabon Georgia Guernsey Germany Ghana Gibraltar Guinea Guadeloupe Gambia Guinea-Bissau Greece Grenada Greenland Guatemala French Guiana Guam Guyana Hong Kong Heard Island and McDonald Islands Honduras Haiti Hungary Holy See (Vatican City State) Indonesia Isle of Man India Iraq Iceland Israel Italy Jamaica Jersey Jordan Japan Kazakhstan Kenya Kyrgyzstan Kiribati Korea Korea Kuwait Lao Lebanon Liberia Libyan Arab Jamahiriya Liechtenstein Lesotho Lithuania Luxembourg Latvia Macau Morocco Monaco Moldova Micronesia Madagascar Maldives Mexico Marshall Islands Macedonia Mali Malta Myanmar Montenegro Mongolia Mozambique Mauritania Montserrat Martinique Mauritius Malawi Malaysia Mayotte Namibia Northern Mariana Islands New Caledonia Niger Norfolk Island Nigeria Nicaragua Niue Netherlands Norway Nepal Nauru New Zealand Oman Pakistan Panama Pitcairn Peru Philippines Palau Papua New Guinea Poland Puerto Rico Portugal Paraguay Palestinian Territory Qatar Réunion Romania Russian Federation Rwanda Saudi Arabia Sudan Senegal Singapore South Georgia and the South Sandwich Islands Saint Helena Svalbard and Jan Mayen Solomon Islands Sierra Leone Salvador San Marino Somalia Switzerland Saint Pierre and Miquelon Serbia Spain Saint Kitts and Nevis Sao Tome and Principe Suriname Slovakia Slovenia Sweden Saint Vincent and the Grenadines Sri Lanka Saint Barthélemy Saint Lucia Swaziland Seychelles Saint Martin Samoa South Africa Syrian Arab Republic Turks and Caicos Islands Togo Thailand Tajikistan Tokelau Turkmenistan Timor-Leste Tonga Trinidad and Tobago Tunisia Turkey Tuvalu Taiwan Tanzania Uganda Ukraine United States Minor Outlying Islands Uruguay United States Uzbekistan United Kingdom Venezuela Virgin Islands, British Virgin Islands, U.S. Viet Nam Vanuatu Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe [?]
16.	Anticipated start date		[?]
17.	Anticipated end date		[?]
18.	Recruitment status		Please Select Pending Withdrawn Recruiting Suspended Terminated Complete other  [?]
19.	State of ethics review approval		[?]
20.	Funding source(s)		[?]
21.	Applicant's Email
22.	Contact Person for Scientific Queries / Principal investigator [?]
		Name:
		Designation:
		Address:
		Phone:
		Fax:
		Email:
23.	Primary Study Sponsor/ Organization  [?]
		Name:
		Address:
		Phone:
		Fax:
		Email:
		Web:
24.	Contact Person for Public Queries [?]
		Name:
		Designation:
		Address:
		Phone:
		Fax:
		Email:
25.	Secondary Study Sponsor(s), if any [?]
		Name:
		Address:
		Phone:
		Fax:
		Email:
		Web:
	I agree to provide any further details as and when required by the SLCTR. I agree to provide regular progress reports at 6 months, one year, and every year thereafter until trial completion. I agree to inform the SLCTR of any changes made to the trial protocol.
	Date : 30/Jul/2010