APPLICATION FORM for INITIAL REVIEW _____________________________________________________ANNEX 1 Form AF 01-010 APPLICATION FORM for INITIAL REVIEW _____________________________________________________ANNEX 1 Form AF 01-010

STUDY POPULATION
REQUESTED EXCLUSION OF PARTICIPANTS:
IONIZING RADIATION USE (X-rays, radioisotopes, etc):
INVESTIGATIONAL NEW DRUG (IND) / DEVICE (IDE):
PROCEDURE USE:
MULTI-SITE COLLABORATION:
FINANCIAL DISCLOSURE: