Republic of the Philippines
ISABELA STATE UNIVERSITY
INSTITUTIONAL RESEARCH ETHICS BOARD
Application Form for Ethics Review of Research Proposals
Instructions to the Researcher: Please accomplish this form and ensure that you have included in your submission
the documents that you checked below (in Section 3. Checklist of Documents).
I. GENERAL INFORMATION
TITLE
OF STUDY
REC CODE
(To be provided by STUDY
REC) SITE
NAME TEL NO:
OF CONTAC MOBILE NO:
RESEARCHER T
INFORMA FAX NO:
CO-
TI ON
RESEARCHER/S EMAIL:
(if any)
NAME OF
INSTITUTION
INSTITUTION
ADDRESS
□ Clinical Trial □ Biomedical research (Retrospective,
(Sponsored) Prospective and Diagnostic Studies)
□ Clinical Trials □ Stem Cell Research
(Researcher-Initiated) □ Genetic Research
TYPE OF STUDY □ Health □ Internet Research
Operations □ Others:
Research
(Health Programs and
Policies)
□ Social
or Behavioral
Research
□ Public
Health or
Epidemiologic
□ Multicente □ Multice □ Single Site
r nter
(International) (National)
□ Sponsoredby Pharmaceutical Company
□ Self-Funded Specify:
SOURCE
□ Government-Funded
OF FUNDING □ Scholarship/ □ Others:
Research Grant
□ Institution-Funded
START DATE: NUMBER
DURATION
OF THE STUDY
OF STUDY
END DATE:
PARTICIPAN
TS
1
ISUE-IRE-AFE-009
Effectivity: March 25, 2024
Revision: 0
Republic of the Philippines
ISABELA STATE UNIVERSITY
INSTITUTIONAL RESEARCH ETHICS BOARD
HAS THE RESEARCH
□ YES
UNDERGONE TECHNICAL (please attach □ NO
REVIEW? technical
review results)
HAS THE RESEARCH BEEN
SUBMITTED TO ANOTHER □ YES □ NO
RESEARCH ETHICS
COMMITTEE?
II. BRIEF DESCRIPTION OF THE STUDY (use additional sheet if necessary)
III. CHECKLIST OF DOCUMENTS FOR SUBMISSION
BASIC REQUIREMENTS: SUPPLEMENTARY DOCUMENTS (if
□ Letter request for review applicable):
□ Endorsement/Referral Letter □ Questionnaire
□ Foreign Institutional □ Data Collection Forms
Ethics Review Approval (if □ Product Brochure
applicable) □ Philippine FDA Marketing
□ Full Proposal/Study Protocol Authorization or Import License
□ Technical Review Approval □ Permit(s) for special populations
□ Curriculum Vitae of Researcher
□ Informed Consent Form
□ English version □ Others
□ Filipino version
□ Others
□ Assent Form (if applicable)
□ English version
□ Filipino version
□ Others
ACCOMPLISHED BY: DATE SUBMITTED:
(Signature over printed name)
------------- TO BE FILLED OUT BY THE REC SECRETARIAT -------------
COMPLETENESS OF □ Complete
DOCUMENT □ Incomplete
REMARKS
DATE RECEIVED: (place stamp here)
RECEIVED BY:
2
ISUE-IRE-AFE-009
Effectivity: March 25, 2024
Revision: 0
Republic of the Philippines
ISABELA STATE UNIVERSITY
INSTITUTIONAL RESEARCH ETHICS BOARD
3
Republic of the Philippines
ISABELA STATE UNIVERSITY
INSTITUTIONAL RESEARCH ETHICS BOARD