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USTFMS ERB F01 Application Form

The document is an application form for ethics review of research projects by the University of Santo Tomas Faculty of Medicine and Surgery Ethics Review Board. The form requests information about the research protocol, investigators, sponsor, study sites, required laboratory procedures, and declarations of conflict of interest from the principal investigator.

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Jeriz Marie Gamboa
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258 views2 pages

USTFMS ERB F01 Application Form

The document is an application form for ethics review of research projects by the University of Santo Tomas Faculty of Medicine and Surgery Ethics Review Board. The form requests information about the research protocol, investigators, sponsor, study sites, required laboratory procedures, and declarations of conflict of interest from the principal investigator.

Uploaded by

Jeriz Marie Gamboa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

UNIVERSITY OF SANTO TOMAS

FACULTY OF MEDICINE AND SURGERY


ETHICS REVIEW BOARD
España Blvd., Manila 1015 Philippines

ERB APPLICATION FORM


Receiving Stamp/
Instruction: Attach this form to the initial submission/resubmission of protocol Date of Submission:
packages/dossier.

For further information, contact:


Ms. Rhea Llemos
The ERB Secretariat
nd
USTFMS ERB Office: 2 Floor St. Martin de Porres Bldg.
Tel No (+632) 7861611 local 8292

Protocol
No./
Title:
Principal Investigator:

Address: Contact Nos.:


E-mail Address:
Co-Investigator: Department/Section:

Office Address: Contact Nos.:


E-mail Address:
Sponsor:
Office Address: Contact Nos.:
Fax Phone:
Contract Research Organization (CRO):
Office Address: Contact Nos.:
Fax Phone:
Research Coordinator: Contact Nos.:
Category of Company Investigator Investigator Consultants UST Non- UST
Study/ Sponsored Initiated/ Initiated/ Faculty Students
Investigator Funded Non-Funded

clinical trial (RCT), placebo- epidemiology basic research social research; herbal
controlled, double-blind research
Types of process research/ diagnostic genetic/genomic health informatics in-vitro study
research operations
review of medical records; survey research on others
indigenous
Use of children under 19 indigenous elderly homeless pregnant
special people persons women
population patients in emergency care poor & refugees or patients w/ incurable others
unemployed displaced persons disease
Clinical No. of Subjects: Study Budget for UST-FMS:
Trial I II III IV PMS
Phase: (attach copy)
Study Site (specify office location): Study Duration:

Review Fee: (specify amount) Institutional Fee: (specify amount)

Bank Name/ Bank Name/


Check No.: Check No.:
Payment Status: Charge Slip No./ Payment Status: Charge Slip No./
Paid: Cancelled: Paid: Cancelled:
Verified by: ERB Secretary Official Receipt No. Verified by: ERB Secretary Official Receipt No.

Required UST: (Attach list) Central Lab: Other Local Labs:


Laboratory/ (specify name of Central Lab) Not acceptable
Ancillary
Procedures
I have no conflict of interest in any form (financial, proprietary, professional) with sponsor, the study, Co-
Investigators, or the site.

Declaration

Page | 1
of Conflict of I have personal/family financial interest in the results of the study
Interest (COI) Nature:
of Principal
Investigator
(PI) I have proprietary interest in the research (patent, trademark, copyright, licensing)
Nature:

<Title, Name, Surname>


Submitted
by: Study Designation: PI Signature:

To be filled-out by the USTFMS ERB Administrative Secretary:


Date of Initial Review: Date of Approval: ERB Reference No.

Clinical Trial Agreement: Date of Validity: Documents checked by:

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