CSMC RERC FORM 2A.

2
REQUIREMENT CHECKLIST – INITIAL
SUBMISSION
PHYSICIAN – INITIATED RESEARCH
Page 1 of 2

CSMC RERC CODE DATE OF SUBMISSION

           
CATEGORY OF INVESTIGATOR
Resident Postgraduate Intern Consultant
Fellow Nursing Allied Medical
YEAR LEVEL DEPARTMENT/INSTITUTE

           
PRINCIPAL INVESTIGATOR CONSULTANT ADVISER (If applicable)

           
PROTOCOL TITLE

     
TARGET NUMBER OF PARTICIPANTS IN CSMC STUDY DURATION

           
Please NO. OF
DOCUMENTS SUBMITTED
check COPIES
3 Accomplished Application Form (Form 2B.2)
3 Protocol Assessment Form (Form 2D.2)
3 Informed Consent Assessment Form (Form 2E) – If applicable
3 Request for Waiver of Informed Consent, if applicable
Letter of Intent addressed to PURA R. CAISIP, M.D., Chair, Research Ethics Review
3
Committee
Letter of Endorsement from Department Chairman addressed to Dr. PURA R. CAISIP, Chair,
3
Research Ethics Review Committee
Technical Review Certificate issued by CSMC Research Center or Non-CSMC equivalent
3
Research Approval Authority
3 Detailed Protocol including Gantt chart with timeline for research ethics approval
3 Informed Consent Forms in English, Tagalog, and other dialect if applicable
3 Questionnaires – if applicable
3 Copy of Letters to Authorities seeking Permission to Conduct the Research
3 Study Budget and source of funds – If applicable
3 Curriculum Vitae and GCP Certificate of Investigator
1 Electronic copy of the protocol (email to csmcethicscommittee@csmc.ph)
REVIEW FEE:
Researches initiated by CSMC Physicians-in-Training are exempted from paying review and institutional fees.
Researches initiated by Non-CSMC Physicians/Investigators (Physician-in-training, Nurses, Undergrad and graduate
thesis and other health professionals) shall be subject to PHP 5,000 review fee.
 CSMC RERC FORM 2A.2
REQUIREMENT CHECKLIST – INITIAL
SUBMISSION
PHYSICIAN – INITIATED RESEARCH
Page 2 of 2

CSMC and Non-CSMC Physician/ Investigator Initiated researches with funding Php 250,000 and above budget shall be
subject to 5% of the total budget review fee.

CSMC and Non-CSMC Physician/ Investigator initiated researches with funding less than Php 250,000 budget shall be
subject to PHP 5,000 review fee.
Submit the requirements to the Office of Research Ethics Review Committee, 3 rd Floor Medical Arts Building 1 (MAB 1).
Contact numbers – Direct Line +632 721 0334; Trunk Line +632 7270001 – 17 Local 3799.
RERC CONTACT PERSONS
JANICE N. BACARISAS
IRENE P. ROCA/ Administrative Supervisor, RERC Secretary, RERC
SUBMITTED BY (Printed Name and Signature of Applicant) DATE

           

RECEIVED BY (Printed Name and Signature of CSMC RERC Staff) DATE RECEIVED