Al-Quds University – Research Ethics Committee
RESEARCH ETHICS CHECKLIST
Instructions for applicants:
This checklist should be completed for every research project which involves
human participants and including personal, medical or otherwise sensitive data or
methodologically controversial approaches. This checklist must be completed
before potential participants are approached to take part in any research. The
research ethics review process is not designed to assess the merits of the
research project in question, but is merely a tool to ensure that ethical
considerations have been fully considered and ethical issues have been properly
dealt with when arise.
Before completing this form, please read the Code of Good Practice in Research of
Al-Quds University and the Ethical principles for medical research involving
Human subjects (the most recent version of the Helsinki Declaration). The
principal investigator and, where the principal investigator is a student, the
supervisor, are responsible for exercising appropriate professional judgment in
this review.
Complete all sections of this checklist as accurate as possible. After completing
sections I to IV, check the following: If all items in the Declaration in section III are
ticked AND if you have answered NO to all questions in section IV (questions 1-
14), send the completed & signed copy of this form to the Head of your
faculty/center/institute and a copy to the REC office for information. You may
proceed with the research project but you should follow any subsequent
guidance or requests from the faculty/centre/institute or your supervisor where
appropriate. Undergraduate and postgraduate students should retain a copy of
this form and submit it with their research report or thesis (bound in the
appendix). Also, graduate students should submit a copy of this form to the
Deanship of Graduate Studies (DGS) when seeking registration for thesis’ defense
(Forms 5 & 6 of DGS). Work which is submitted without the fully completed copy
of this form will be returned unassessed or cannot complete the defense of
their thesis.
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If ANY of the items in the Declaration in section III are not ticked AND / OR if you
have answered YES to ANY of the questions (1-13) in Section IV, you will need to
describe more fully in Section V of this form below how you plan to deal with the
ethical issues raised by your research. This does not mean that you cannot do the
research project, only that your proposal will need to be approved by the
faculty/centre/institute or REC. After completing section V as described in the
above paragraph, submit a copy of this form with properly filled section V to the
faculty/centre/institute and REC office along with the Application form.
If you answered YES to question 14, you will also have to submit an application to
the appropriate external health authority ethics committee, after you have
received approval from the faculty/centre/institute or REC office.
Section I: Applicant details
1. Name of principal investigator
(applicant): Mohammad Amouri
1a. Associated investigators: Salahaldeen Deeb, Mohannad
Samaheen, Maen Mohammad, Sarah
Warasna, Areen Amleh, Osamah
Rimawi, Yahya Abushaqra, Osama
Jaber, Nour Sourkhi, Ahmad Thabet,
Mutaz Sultan, Mutea Abu Awad,
Wael Amro, and Nisreen Rumman
2. Status (please click to select): Medical Doctor
3. Email address: Mohammadamouri95@[Link]
4a. Contact address: Ramallah
4b. Telephone number: 0592877543
Section II: Project details
5. Project title: Diagnostic Techniques, Long-term
Outcomes and Management Strategies
For Esophageal Atresia With or Without
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Tracheoesophageal Fistula Patients in
Palestine: A Multicenter Retrospective
study from 2013 to 2024
Section III: For Students only:
6. Course title and module name and
number where appropriate
faculty/centre/institute:
7. Supervisor’s or module leader’s Dr. Nisreen Rumman
name:
8. Email address: rummannisreen@[Link]
9. Telephone extension: 0599433939
Declaration by researcher (please tick the appropriate boxes)
Yes I have read the Code of Good Practice in Research of Al-Quds University
Yes The topic merits further research
Yes I have the skills to carry out the research
Yes The participant information sheet, if needed, is appropriate
Yes The procedures for recruitment and obtaining informed consent, if
needed, are appropriate
Yes The research is exempt from further ethics review according to current
University guidelines
Comments from researcher, and/or from postgraduate student:
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Section IV: Research
Please answer each question by ticking the appropriate box:
YES NO
1. Will the study involve participants who are particularly Yes
vulnerable or who may be unable to give informed
consent (e.g. children, people with learning disabilities,
emotional difficulties, problems with understanding
and/or communication, your own students)?
2. Will the study require the co-operation of a gatekeeper for No
initial access to the groups or individuals to be recruited
(e.g. students at school, members of self-help group, and
residents of nursing home)?
3. Will deception be necessary, i.e. will participants take part No
without knowing the true purpose of the study or without
their knowledge/consent at the time (e.g. covert
observation of people in non-public places)?
4. Will the study involve discussion of topics which the No
participants may find sensitive (e.g. sexual activity, own
drug use)?
5. Will drugs, placebos or other substances (e.g. food No
substances, alcohol, nicotine and vitamins) be
administered or ingested by participants or will the study
involve invasive, intrusive or potentially harmful
procedures of any kind?
6. Will blood or tissue samples be obtained from No
participants?
7. Will pain or more than mild discomfort be likely to result No
from the study?
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8. Could the study induce psychological stress or anxiety or No
cause harm or negative consequences beyond the risks
encountered in normal life?
9. Will the study involve prolonged or repetitive testing? No
10. Will financial inducements (other than reasonable No
expenses and compensation for time) be offered to
participants?
11. Will participants’ right to withdraw from the study at any No
time be withheld?
12. Will participants’ anonymity be compromised or their right No
to anonymity be withheld or information they give be
identifiable as theirs?
13. Might permission for the study need to be sought from No
the researcher’s or from participants’ employer?
14. Will the study involve recruitment of patients or staff No
through the National Health Information System, (NHIS)?
Section V: Addressing ethical problems
If you have answered YES to any of questions 1-13 please complete below and
submit this form to your faculty/centre/institute or REC.
Project title
Diagnostic Techniques, Long-term Outcomes and Management Strategies For
Esophageal Atresia With or Without Tracheoesophageal Fistula Patients in
Palestine: A Multicenter Retrospective study from 2013 to 2024
Principal investigator/student
Mohammad Amouri
Supervisor (if principal investigator)
Dr. Nisreen Rumman
Summary of issues and action to be taken to address the ethics problem(s)
Key issues are using minors’ medical records and a higher risk of re-
identification in a rare condition; to address these, we will obtain ERC approval
with a consent waiver, collect only minimum necessary data, assign coded
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study IDs with a separate linkage file, use encrypted access-controlled storage
and secure transfer, and disseminate only de-identified aggregate results with
small-cell suppression and defined retention/secure deletion.
Please note that it is your responsibility to follow the Code of Good Practice in
Research of Al-Quds University and any relevant academic or professional
guidelines in the conduct of your research project. This includes providing
appropriate information sheets and consent forms, and ensuring confidentiality
in the storage and use of data. Any significant change to the design or conduct of
the research should be notified to the faculty/centre/institute or REC office and
may require a new application for ethics approval.
Signed: Mohammad Amouri Principal Investigator
Approved: Dr. Nisreen Rumman Supervisor
or module leader (where appropriate)
Date: 22/08/2025
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For use by faculty/centre/institute or REC office:
● No ethical problems are raised by this proposed research -
Retain this form on record
● Appropriate action was taken to maintain ethical standards
● The research protocol should be revised to eliminate the
ethical concerns or reduce them to an acceptable level,
using the attached suggestions.
● Please submit faculty/Centre/institute application
for Ethics Approval
● Please submit REC Application for Ethics Approval
Retain this form on record and
Signed: return a copy of section V to
Researcher
Date:
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