Application to conduct I ndependent Ethics Committee Ramsay Sime Darby Health Care Research Principal PI Institution Investigator’s (PI) Name & Stamp Contact No: Email: Co Investigators Institution (If any) Study Coordinator(if Contact No any) Title of Project NMRR ID National Medical Research Registry (NMRR) registration is compulsory for Clinical Trials or Research involving Drugs Protocol Number (if Current Version Date (if available): available) Purpose of study Academic requirement (Thesis, Dissertation, Training Requirement) Independent research work Multi-institutional or multi-country collaboration Others (indicate): No Yes: Has this project been submitted or is planned for submission to any other ethics committee(s) in Malaysia? If Yes, please provide name and contact details of the Ethics Committee/IRB(s), and indicate the status of the application. If rejected, state reasons given by that Ethics Committee for its disapproval/rejection or provide a copy of the letter of disapproval/rejection Has this proposal been rejected by any IEC/ IRB? No Yes: If yes, please provide details for the rejection:
I ndependent Ethics Committee Ramsay Sime Darby Health Care Application to conduct Research Principal Investigator’s (PI) Name & Stamp PI Institution Contact No: Email: Co Investigators (If any) Institution Study Coordinator(if any) Contact No Title of Project NMRR ID National Medical Research Registry (NMRR) registration is compulsory for Clinical Trials or Research involving Drugs Protocol Number (if available) Current Version Date (if available): Purpose of study Academic requirement (Thesis, Dissertation, Training Requirement) Independent research work Multi-institutional or multi-country collaboration Others (indicate): Has this project been submitted or is planned for submission to any other ethics committee(s) in Malaysia? No Yes: If Yes, please provide name and contact details of the Ethics Committee/IRB(s), and indicate the status of the application. If rejected, state reasons given by that Ethics Committee for its disapproval/rejection or provide a copy of the letter of disapproval/rejection Has this proposal been rejected by any IEC/ IRB? No Yes: If yes, please provide details for the rejection:
Research-Application-Form-Submission-2016-12-Fillable-form.docx