No. Pengajuan : ……………………..

KOMITE ETIK PENELITIAN MEDIS & KESEHATAN

FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN KRIDA WACANA (UKRIDA)
Medical and Health Research Ethics Committee
Faculty of Medicine Krida Wacana Christian University (Ukrida)

Keterangan Lolos Kaji Etik

Ethical Clearance

Komite Etik Penelitian Medis dan Kesehatan, Fakultas Kedokteran Universitas Kristen Krida Wacana
dalam upaya melindungi hak asasi dan kesejahteraan subyek penelitian kedokteran, telah mengkaji
dengan teliti Protokol berjudul:
The Ethics Committee of the Faculty of Medicine Krida Wacana Christian University, with regards of
the protection of human rights and welfare in medical research, has carefully reviewed the research
protocol entitled
…………….………………………………………………………………………………………………
………….…………………………………………………………………………………………………

Peneliti utama : ……………………………………

Principal investigator

Nama institusi : ………………………………..

Name of Institution

Telah menyetujui protokol tersebut di atas.

Have approved the above mentioned protocol

Catatan: Peneliti wajib menjaga kerahasiaan identitas subyek penelitian

The investigators should keep the subject indentity confidentialty

Jakarta,

Fakultas Kedokteran Universitas Kristen Krida Wacana (UKRIDA)

Faculty of Medicine Krida Wacana Christian University (Ukrida)

Ketua Komite Etik Penelitian Medis & Kesehatan

Head of Medical and Health Research Ethics Committee

dr. Indriani K. Sumadikarya, MS