PHREB ACCREDITATION FORMS

Form No. 1.3

Page Page 1 of 2
RESEARCH ETHICS COMMITTEE PROTOCOL SUMMARY
Version Date 22 Mar 2016
Version No. 02

A. RESEARCH ETHICS COMMITTEE (REC) INFORMATION

Name of Ethics Review

Click here to enter text.
Committee:
Name of Institution: Click here to enter text.
Address: (No., Street,
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Town/City, Province, Region)
Report prepared by: Click here to enter text.
Name of Contact Person: Click here to enter text.
Position: Click here to enter text.
Telephone: Click here to enter text.
Mobile: Click here to enter text.
REC Email
Fax: Click here to enter text. Click here to enter text.
Address:
IMPORTANT REMINDER: LEVEL 1 AND 2 RECs CANNOT REVIEW CLINICAL TRIALS OF DRUGS FOR FDA REGISTRATION

B. PROTOCOL SUMMARY

Date of
Date of
Meeting
REC First
Names of Resear Revie where Name of
Protoc Fundin Date Decisio Decision Stat
Protocol Title Researcher(s)/ ch w Protocol is Primary
ol ga Received nd Letterto the us
Investigator(s) Typeb Typec First Reviewer
Code PI /
Discussed
Researcher
(if full review)
<MM-DD- Primary <MM-DD-
XXXXX Protocol Title Researcher R B FR <MM-DD-YY> A OR
YY> Reviewer YY>
XXXXX Protocol Title Researcher R B <MM-DD- FR <MM-DD-YY> Primary A <MM-DD- OR
Legend:
a a c d
FUNDING Research Type REVIEW TYPE DECISION STATUS
R - Researcher-funded Biomedical studies FR – Full Review A – Approved OR – On-going review
I - Institution-funded Health Operations Research ER – Expedited Review MN – Minor modification A – Approved and on-going
A - Agency other than institution EX – Exempt from Review MJ – Major modification C- Completed
D - Pharmaceutical companies Social Research D – Disapproved T – Terminated
O - Others Public Health Research W– Withdrawn
Clinical Trials
 PHREB ACCREDITATION FORMS
Form No. 1.3
Page Page 2 of 2
RESEARCH ETHICS COMMITTEE PROTOCOL SUMMARY
Version Date 22 Mar 2016
Version No. 02

YY> Reviewer YY>

<MM-DD- Primary <MM-DD-
XXXXX Protocol Title Researcher R B FR <MM-DD-YY> A OR
YY> Reviewer YY>
<MM-DD- Primary <MM-DD-
XXXXX Protocol Title Researcher R B FR <MM-DD-YY> A OR
YY> Reviewer YY>
<MM-DD- Primary <MM-DD-
XXXXX Protocol Title Researcher R B FR <MM-DD-YY> A OR
YY> Reviewer YY>
*Add rows when needed

How many of the above protocols came from researchers belonging to other institutions? ___________

Legend:
a a c d
FUNDING Research Type REVIEW TYPE DECISION STATUS
R - Researcher-funded Biomedical studies FR – Full Review A – Approved OR – On-going review
I - Institution-funded Health Operations Research ER – Expedited Review MN – Minor modification A – Approved and on-going
A - Agency other than institution EX – Exempt from Review MJ – Major modification C- Completed
D - Pharmaceutical companies Social Research D – Disapproved T – Terminated
O - Others Public Health Research W– Withdrawn
Clinical Trials