Health Sciences Ethics Office for Research, Training and Support

health-sciences.nwu.ac.za/healthethics

HREC - Health Research Ethics Committee Withdrawal of an Ethics Application in Process i.e. to retract any application already submitted but not yet approved 9.1.5.6_HREC_Withdrawal, Version: June 2018
CONFIDENTIAL! This document contains confidential information that is intended strictly and exclusively for the applicant and HREC Committee. Should this document or parts thereof erroneously come in your possession, you are requested to destroy it or to return it to the HREC without delay. Unauthorised possession, reading, studying, copying or distribution of this material, or any other form of abuse, is illegal and punishable.

General Project Identification
Applicant to complete this table BEFORE sending it off for signing.
Project Head (Title, Initials & Surname)	Click or tap here to enter text.
Project Title (see Application Form)	Click or tap here to enter text.
Date Submitted	Click or tap to enter a date.
NWU Ethics Number (see Application Form)	NWU- ?????-??-S? (as assigned)

This form is to be completed by the Project Head (e.g. principle investigator / study leader), who submitted the HREC Ethics Application Form.
Please note! This form may be filled in and signed electronically, and then converted to PDF (recommended), or printed to complete and signed if not possible.

Declarations by the Project Head

I, the undersigned, hereby formally retract the abovementioned ethics application as submitted, but not yet approved. I realise that by doing so, this application will be removed from the list of applications in process. I also realise that this withdrawal of the application implies that I will have to apply anew (i.e. from the start as a new application) if I want approval for this project in future, and that a new ethics number will then be assigned. I also realise that the project described in the retracted application may not commence and that I may not use or misuse the allocated ethics number.

Name (Title, Full Names & Surname)
Click or tap here to enter text.
Date
Click or tap to enter a date.	Signature
Reason for withdrawal Click or tap here to enter text.

Original details: (23239522) G:\My Drive\Documents\_Etiekkantoor\Ethics Office Website\Apr 2018 Updating\HREC\Appl Forms\Larger Studies\[HREC 02-06a v4.11] Withdraw application in process_Apr2018.docm
18 April 2018

File Reference: 9.1.5.6