Health Technology Assesment Request Form

Important Information

This form is to be completed by the person requesting an evaluation of a new health intervention or technology or re-evaluation of an existing practice. Providing as much detail as possible will enable TAU to complete a balanced and expeditious evaluation.

1. Are the relevant Department and Divisional Heads aware and in support of this request for an evaluation?

Please provide the name and email of the person who approved the request:

Name of Approver

Email of Approver A PDF of this completed request form will be emailed to the Approver This question requires a valid email address.

Please obtain approval from the relevant heads before continuing with this request