Application for a Fee Reduction / Fee Waiver to the

Ethics Committee of the Heidelberg Medical Faculty

(applies solely to professional legal advice acc. to Sec. 15 (1) of the Medical Code for Baden-Wuerttenberg (BOÄ BW) and Statements acc. to Sec. 9 (1) third sentence of the State Cancer Register (LKrebsRG)

Name of Principal Investigator:	Click here to enter text.
Clinic/Department:	Click here to enter text.
Title of the Study:	Click here to enter text.
Designation of the external sponsor (full name, address) This information is mandatory (where applicable)	Click here to enter text.

The proper implementation of medical research projects within the meaning of the Declaration of Helsinki can only be warranted, insofar as a study has sufficient financial and personnel resources.

We nevertheless request a fee reduction/waiver for the evaluation of the aforementioned study for the following reason (only one choice is possible):

☐ Research project with external funding (fee reduction of 50%)

The regular fee cannot be completely covered by the sponsor’s funds and the difference cannot be borne by funds from the investigator’s own department.

☐ Research project without external funding (fee reduction of 50%)

The regular fee cannot be covered by funds from the principal investigator’s own department.

☐ Research project without external funding (fee waiver)

Neither the regular fee nor a reduced fee can be covered by funds from the principal investigator’s own department.

To obtain a fee reduction or a fee waiver, it must be convincingly presented in the following how a proper conduction of the study will be ensured without any financing or with scarce funds (a justification is mandatory): Click here to enter text According to our Fee Schedule the financing of the research project must be disclosed with an application for a fee reduction or a fee waiver Therefore specific documents regarding the financing must be attached to this application, otherwise the application cannot be processed.

I affirm the completeness and the accuracy of my information. I am aware that false statements may have consequences. I will communicate any changes in the information contained in this application without undue delay. I am familiar with the current valid Fee Schedule of the Ethics Commission of the Heidelberg Medical Faculty.

Click here to enter text

Place, Date	Signature of the Principal Investigator