Download application for protocol review

Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
ETHICS REVIEW COMMITTEE
APPLICATION FOR PROTOCOL REVIEW
ERC Protocol No.:
Sponsor Protocol No.:
Type of Submission:
Submission Date:
 Initial Interview
 Continuing Review
 Resubmission for re-review
 Protocol Termination
 Protocol Amendments
 Final Report
Protocol Title:
Principal Investigator:
Telephone Number:
Mobile No.:
E-mail Address:
Fax No.:
Preferred
 Phone
 Cellphone
Contact
 Fax
 Email
Institution:
Sponsor:
Conflict of Interest
Declaration
(Relationship with
sponsor)
Are you a regular employee of the sponsor?
 Yes
 No
Do you do consultancy or part time work for the
sponsor?
 Yes
 No
 Yes
 No
In the past year, did you receive P250, 000.00 or
more from the sponsor?
Other ties with the sponsor
PI Signature:
Type of Research: (Clinical Trial, Genetic,
Social Science, etc.)
_____________________________________
Phase 1, 2, 3, 4:
_____________________________________
Received by:
_____________________________________
Date:
_____________________________________
BGHMC-ERC-Form-03-005 Rev.0