Research must be conducted according to ethical principles, guidelines for responsible research conduct, legislation and regulations. Research governance is about responsibility and about managing risk. 

Apply for Research Governance (SSA) approval

Research governance is a framework through which institutions are accountable for the research they allow to be conducted under their auspices.

The following information applies to all research projects conducted at or by Melbourne Health, including RMH, VIDRL and NWMH, irrespective of whether the Melbourne Health Human Research Ethics Committee (HREC) has provided ethical review for the project.

Note: Research governance applications for projects reviewed by the MH HREC MUST BE submitted within 12 months of obtaining ethical approval. Where research governance applications have not been received in this time frame the ethical approval will be withdrawn.

COVID-19 Guidance for Research Studies including Clinical Trials

For updates on how COVID-19 impacts research (including review of research governance applications) and updated requirements at Melbourne Health please visit our COVID-19 webpage.

For new Covid-19 related studies please also refer to information from the Co-ordinating Office for Clinical Research (DHHS) (visit the COVID-19 webpage and scroll down).

Hints for completing Research Governance Applications

  • Read all of the steps in the process (including information dropdowns) before commencing with your application
  • Note that the numbering system is arbitrary and that multiple steps can be undertaken in parallel to save you time
  • You can start preparing the application along side the ethics application

  • You can submit the research governance application at the same time as the ethics application or even before you receive ethical approval

  • You should start obtaining departmental/service approvals as soon as possible after the protocol has been finalised

  • Identify if you require an agreement early in the application preparation process and start drafting it

  • Governance approval can only be be issued after ethical approval has been obtained
IMPORTANT: The Office for Research will only accept complete research governance applications

All Research Governance applications will only be accepted by the Office for Research as one complete package.

  • Do not try to submit your governance application in multiple separate parts. This instruction applies to all governance applications, including those for commercially sponsored clinical trials.
  • Incomplete applications will not be accepted and will be returned to the principal investigator and study contact without being reviewed.

Why are we enforcing this instruction?

Receiving a complete application in one package allows that application to be reviewed once, as opposed to multiple times. This promotes efficiency and will allow the Office for Research team to provide a more timely and comprehensive service to all of our researchers and research partners.

1. For Investigator-initiated Melbourne Health-led research projects

For studies where Melbourne Health will formally act as sponsor of a research project, including:

  • MH sponsored clinical trials (CTN/CTX clinical trials within the scope of the Therapeutic Goods Act); and
  • All MH-led multi-site studies

At least six (6) weeks before the intended submission deadline date call the Office for Research on 9342 8530 to confirm whether an MH Sponsorship Review Meeting is required for your project.

This process must be completed before a trial/study application can be accepted for ethics and/or governance review.

2. Obtain a local HREC Project Number

Prior to submitting your application, contact the Office for Research to obtain a Local HREC Project Number.

  • If you have submitted an ethics application to the Melbourne Health HREC, you will already have this number.
  • If your research project is a commercially sponsored clinical trial, please ensure that you obtain this number immediately upon confirmation of site selection by the sponsor.
  • If you have received ethical approval from an ethics committee other than the MH HREC you will still need a local HREC Project Number for your governance application.

The Local HREC Project Number must appear on all components of your governance application.

3. Confirm date of site selection (if applicable)

For externally sponsored clinical trials, enclose a copy of the correspondence from the sponsor confirming selection of Melbourne Health as a participating site in the trial - include the corresponding project number.

4. Complete the Research Governance Checklist

Download and complete the Research Governance Checklist from the Department of Health.

5. Complete the Governance Cover Letter

Download and complete the Research Governance Cover Letter from the Department of Health

Address the cover letter to Dr Angela Watt - Research Governance & Ethics.

6. Submit a Victorian Site-Specific Assessment form

Submit a Victorian Site-Specific Assessment (SSA) Form via Ethics Review Manager (ERM), complete with e-signatures of all MH researchers.

For help using ERM, download a copy of the Applicant User Guide to ERM.

For investigators in states other than Victoria and Queensland

Instructions for investigators on how to create an SSA form for jurisdictions that do not use ERM can be found under the heading NMA Research Governance/Site Specific Assessment (SSA) Application on the DHHS website at:

Help and support

Infonetica Helpdesk

02 9037 8404

DHHS Victoria

03 9096 7394

7. If your project involves ionising radiation and/or MRI

For all Melbourne Health governance involving ionising radiation (including pre-MRI safety screening examinations):

Where radiation (including pre-MRI safety screening examinations) is not additional to standard care

If radiation exposure (including pre-MRI safety screening examinations) in a research project is not additional to standard clinical management/care at Melbourne Health the Principal Investigator must provide a copy of the confirmation letter reviewed by the HREC using the template available on the Department of Health's Clinical Trials and Research website and must have been included in the ethics application submitted to the reviewing HREC.

Where radiation (including pre-MRI safety screening examinations) is additional to standard care

If radiation exposure (including pre-MRI safety screening examinations) in a research project is additional to standard clinical management/care at Melbourne Health, please provide a copy of the independent assessment report conducted by a Medical Physicist.

8. Complete fee payment form

Download and complete the Application and Amendment Payment Form. Fees are payable up-front, at the time of initial submission of your Research Governance application.

Find out more about research fees and payment.

9. Provide a copy of all HREC documentation where ethics review was not undertaken by Melbourne Health

If Melbourne Health is only responsible for the review of the research governance application (i.e., HREC approval was granted by another institution), provide an electronic copy of the following:

  • The HREC approval letter
  • All the approved HREC documents such as the protocol, IB, participant information and consent form, the signed NEAF, the signed VSM, ionising radiation documentation, etc.
10. Complete site specific PICFs

Complete a site specific Participant Information and Consent Form (PICF) for The Royal Melbourne Hospital if the study involves participants from whom you are obtaining consent.

  • Complete the site specific PICF based on the final Master PICF template approved by the reviewing HREC Committee.
  • Ensure the footer of site specific PICF references the final HREC approved Master version.
  • PICFs must be submitted electronically in MSWord format - not PDF.

Contact details for the PICFs:

For Melbourne Health site complaints

Complaints contact person


Director Research Governance and Ethics


Complaints Manager


(03) 9342 8530

11. Submit a project budget for review

All researchers who are planning to undertake a research project at MH or who are planning to use MH resources to undertake a research project must email the Management Accountant – Research (MAR) at

Budget Review Submission

Where applicable, the following documentation and information is required for the budget review and should be emailed to

Required documentationDescription

Clinical trial research agreement (CTRA); or
Funding agreement / Letter of offer;
Details of how resources that will be used to conduct the project will be funded

The CTRA, funding agreement or letter of offer should detail the source of external funding for the project.

A completed draft version of the relevant agreement for preliminary review is sufficient. A finalised version of the agreement will then be required for final budget approval.

Project protocol or proposal

A project protocol is the document that describes the objective(s), design, methodology, statistics and organisation of a project.

Statement of approval form (SOA)

An SOA must be completed and signed by the head of department for each RMH department used to conduct the project.
This includes, but is not limited to, departments that will be used for services, staff, infrastructure or recruitment purposes.

Estimated labour time

Provide details of the estimated time that all RMH staff members will contribute to the conduct of the study using the Estimated Labour Time Template.

Details of other project expenses

Consider any other project expenses. These expenses may include, for example, archiving costs, capital equipment, ethics fees, meal allowances, postage, printing & stationery, statistial analysis, software, travel allowances, etc.

Internal cost centre numberProvide the RMH cost centre number from which the project will operate.
Participants Provide details of the anticipated number of participants to be recruited at each site and the anticipated recruitment period.

Budget approval notification

The approval will be emailed to you either as:

  • A budget document prepared by the MAR; or
  • A confirmation by the MAR that the project's budget has been reviewed.

Allow at least 3 weeks from the date of the meeting with the MAR for the budget approval notification. The budget approval must then be submitted to the Office for Research as part of the Governance submission.

Find out more information about the financial documentation and information required by the MAR.

12. Complete statement of approval and departmental forms

Statement of Approval Forms

Complete a Statement of Approval (SOA) form for each MH department used to conduct the project.

Email a copy of all documentation relevant to your research project including the protocol, SOA, associated study manuals and departmental forms (listed below) to the following contacts:

DepartmentContactEmailHard copies
CardiologyDianne ShellyYesLevel 2, Cardiology
Clinical Trials CentreRichard Verrelli
(back-up Angela Watt)
DermatologyAnnette PhemisterYesNA
Health Information ServicesJasmine SoukiYesNA
Medical Photography Studio (formerly Medical Illustration)Amanda Rebbechi
(back-up Joss Dimock)
OphthalmologyElizabeth DangYesNA
PathologyMaria BisignanoYesNA
PharmacyEmma Michael
Eugenia Hong
RadiologyRae Clifton
Mary Lambert
YesRIS/PACS Office
Level 1, Radiology
Respiratory MedicineTim DimitriadisYesNA

Departmental Forms

As well as the SOA, also complete the departmental forms as they apply to your research project.

Department or ServiceInstruction
Pathology Visit the Pathology Clinical Trials web page for instructions
RadiologyReview the Trial Approval Process including the Radiology Research Internal Approval Form which must be completed for all studies
Clinical EngineeringContact Clinical Engineering to obtain necessary forms
Office for ResearchFor any person who will access Melbourne Health patient records and who is not an employee of Melbourne Health, e.g. trial monitor or external researcher, complete an Approval to Examine Records for the Purposes of Research form
Melbourne Private HospitalContact the MPH Research Governance Officer directly to determine specific requirements
13. Complete documentation required for Clinical Trials (if applicable)

For all trials

For drug trials

Also submit the following:

Find out more about financial information regarding invoicing and payment clauses to be included in the clinical trial research agreement.

For device trials

Also submit the following:

Find out more about financial information regarding invoicing and payment clauses to be included in the agreement.



For all CTRAs and CIRAs to which MH is a party, complete the “Institution” details on page one as follows:

Name: Melbourne Health
Address: The Royal Melbourne Hospital, City Campus, 300 Grattan Street, Parkville, Victoria, 3050
ABN: 73 802 706 972
Contact for Notices: Executive Director of Research
Fax for Notices: (03) 9342 8548
Phone Number: (03) 9342 8530


For all indemnities given by sponsors to Melbourne Health, please complete the “To” or (“the Indemnified Party”) section on page one as follows:

Name: Melbourne Health
ABN: 73 802 706 972
Address: The Royal Melbourne Hospital, City Campus, 300 Grattan Street, Parkville, Victoria, 3050

14. Submit an unsigned draft of the agreement where MH and at least one other institution is involved in the study

All research involving Melbourne Health and at least one other institution requires a written agreement. This is required even if there is no funding provided for the project.

Note: For clinical trials, agreements are covered in point 13 above.

For all other collaborations (non clinical/device trials) where MH initiates the project complete the:


  • MH Guide to completing the MACH agreement with comments
  • This template should also be used for interstate and overseas sites.
  • Researchers may use the template a collaborating partner if the protocol was written by the collaborator if the collaborator does not have a suitable template.
  • Where the collaborating organisation wrote th protocol, MH will consider the collaborators template agreement.

Melbourne Health Specific information for Agreements

Legal entity for RMH, VIDRL & NWMHMelbourne Health
ABN:73 802 706 972
Address:300 Grattan Street, Parkville VIC 3050

Please enter details below for MH authorised person for signing research agreements:

Director Research Governance and Ethics
Office for Research
Melbourne Health
300 Grattan Street Parkville VIC 3050

Submit a DRAFT copy of agreement as part of your governance application

  • Submit the unsigned draft agreement in MSWord format for review and comment to the Office for Research as part of your Governance Application. Include as much information as possible in the agreement template.

Only after the agreement has been reviewed and approved by the Office for Research, organise for signatures as instructed below:

For original ink signatures
  • Once all collaborators have agreed in the content of the agreement, forward copies of the agreement (one for each collaborator) to the Office for Research to arrange appropriate sign-off.
  • An original copy of the fully signed agreement will be returned to you. Make a copy of the document to keep in your records and forward the signed original agreement to the collaborating organisation(s) for their records.
For scanned signatures
  • Melbourne Health prefers original ink signatures for agreements. However where a scanned signature is used then it must be a scan of an original ink signature (not a pdf signature).
15. Submit your application
  • We only require hard copies of agreements and indemnities
  • Note that digital signatures can be used in the SSA

Electronic submission

  1. Upload all application documents onto ERM and submit; and
  2. Send an email with ALL application documents as attached files (including the agreement, scanned copies of the original wet ink signatures for e, etc.) to
NOTE: For CTN Submissions

For externally sponsored CTN clinical trials (external sponsors may be commercial, a collaborative group or another hospital)

Upon receipt of the HREC approval from the reviewing HREC, external sponsors can lodge the CTN directly with the Therapeutic Goods Administration (TGA), online. Sponsors are asked to provide the Melbourne Health Principal Investigator with a copy of the TGA's confimration/acknowledgement of the CTN together with a pdf copy of the lodged CTN application to forward to as soon as this is available.

For Melbourne Health sponsored CTN clinical trials (ie investigator initiated trials where there is no external sponsor)

Upon receipt of governance approval letter from Melbourne Health, researchers must make an appointment with the Office for Research, Research Support Officer to lodge the CTN application online together. The fees associated with the CTN submission will be set against the applicable research cost centre.

Direct any questions about the CTN submission scheme to the Research Support Officer.


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