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Home » Compliance & Ethics » Third-Party Grants and Donations Request – Americas » Investigator-Initiated Trial (IIT) Request – Americas

Investigator-Initiated Trial (IIT) Request – Americas

Please fill out the form below for your request to be considered. 

"*" indicates required fields

This form is intended for initial administrative, scientific feasibility, and strategic alignment review by Merit Medical. Completion of this form does not constitute protocol approval or funding commitment.

Investigator & Institution Information

Firstname Lastname
Country / Region of Study Conduct*
Have you obtained approval from your institution for the proposed study?*
If required, has your institution agreed to act as the study sponsor?*

Study Overview

Study Category*
Study Type*
Single- or Multi-Center*

Estimated Timelines

Study Start*
First Subject Enrolled; If you are unsure of the ‘day’, select the 1st of the month

Enrollment Completion*
If you are unsure of the ‘day’, select the 1st of the month

Follow-Up Completion*
If you are unsure of the ‘day’, select the 1st of the month

Support Requested

USD or Local Currency
Product Requested*
Other Support*

Study Summary

Instructions: Please provide a detailed summary of the proposed study design. If a study protocol is available, this can be provided in lieu of the information requested below.
Study Protocol Available*
Drop files here or
Max. file size: 4 GB, Max. files: 10.
    Please upload your protocol files here
    1-2 sentences

    Investigational Device & Procedure

    Follow-up & Assessments

    Sample Size
    Is the study statistically powered?*

    Required Documents

    Please upload the following documents.
    Drop files here or
    Max. file size: 4 GB.
      Drop files here or
      Max. file size: 4 GB.
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        Acknowledgement

        By submitting this grant request you certify that to the best of your knowledge, all information set forth in this form is correct and complete, and is in compliance with Merit’s Compliance Program (attached below). You also certify that the grant is not for the purpose of inducing someone to purchase, prescribe, endorse or recommend a product, or otherwise for the purpose of obtaining or retaining business or gaining an improper business advantage.

        Submission of this Grant Request and the foregoing documentation does not guarantee approval of the request. In addition, past funding does not guarantee future approval. Merit will only pay grants upon approval by the Merit Grant Committee and after the Grant Agreement has been signed by Merit and the Grant Recipient. The Merit Grant Committee reserves the right to award less than the amount requested.

        Firstname Lastname
        Submission Date*

        Signature*

        Privacy Acknowledgement*

        Grants

        • Third-Party Grants and Donations Request – Asia Pacific
          • Grants and Donations FAQs – Asia Pacific
        • Third-Party Grants and Donations Request – Europe (EMEA)
          • Grants and Donations FAQs – Europe (EMEA)
        • Third-Party Grants and Donations Request – U.S. and Other Countries
          • Grants and Donations FAQs – U.S. and Other Countries
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