INVESTIGATOR-INITIATED STUDY Application Form

STRONGBRIDGE BIOPHARMA

INVESTIGATOR-INITIATED STUDY APPLICATION FORM

PRINCIPAL INVESTIGATOR INFORMATION Legal name: Date of application:

Contact name: Phone:

Email:

Address:

STUDY INFORMATION PLEASE ATTACH A COPY OF YOUR FULL STUDY PROPOSAL Study Title:

Therapeutic Area: Study Hypothesis: Primary and Secondary Objectives:

Other: ______Support Requested Please include the type of support, product and/or financial support, including amount/quantities for products.

Estimated total study budget Please attached a detailed line-item budget

State estimated timeline for study completion Please include all phases (initiation, recruitment/enrollment, etc.).

List of attachments to this application (CVs, protocol, budget, IRB approval, etc.):

Additional Information Relevant to this Proposal:

Signature of Principal Investigator: Date:

SECTION BELOW IS FOR INTERNAL USE ONLY GRANT COMMITTEE REVIEW Date Reviewed: COMMITTEE DECISION: APPROVE DECLINE HOLD

Name and signature of Chief Medical Officer: Reviewer Decision: APPROVE DECLINE HOLD

Name and signature of TITLE/POSITION: Reviewer Decision: APPROVE DECLINE HOLD

STRONGBRIDGE BIOPHARMA: Investigator-Inititated Study Application Form Page 1 Version 2: June 2016