LETTER OF UNDERTAKING FOR CLINICIAN

I ___________________________, hereby declare that I have requested convalescent plasma for

administration to my patient named _______________________MR # ________________
Institute_____________________________________________________________________
Date________________ under the trial titled: “Experimental Use of COVID-19 Convalescent
Plasma for The Purpose of Passive Immunization in Current COVID-19 Pandemic in Pakistan in
2020”.
I also declare that:

 I shall maintain the confidentiality of the patient and shall not disclose any information
pertaining to this clinical trial or this trial participant to anyone except the official CRA
at National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi,
Pakistan.
 The patient will be evaluated against all eligibility criteria at and all relevant information
required as per the official study Case Report Form (CRF)
 Informed consent form will be duly signed by the patient/guardian before procedure.
 The documents shared by National Institute of Blood Diseases and Bone Marrow
Transplantation, Karachi, Pakistan shall not be disclosed and shared on any platform and
must be kept confidential.
 The data including pre and post convalescent plasma transfusion as given in CRF will be
shared with National Institute of Blood Diseases and Bone Marrow Transplantation,
Karachi, Pakistan.
Name: ____________________________
Signature: ____________________________
Date: ____________________________
Stamp: ____________________________
Institute: ____________________________