Form 2.

Ethics Review Committee

APPLICATION FOR ETHICAL REVIEW

Instructions to the Applicant: Please accomplish this form in two copies and submit to the
EVHRDC ERC Secretariat together with the 10 copies of the project proposal

Title of Project: ___________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Type of Study: ___ Clinical research ___ Basic Science ___ Genetic
___ Field research ___ Survey ___ others, please specify:
___________________

____ Multicenter (International) ____ Multicenter (Philippines) ____ Single Site

Principal Investigator: __________________________________________________

Institution: ______________________________________________________________

Contact details: Tel. No. ________________ Email address ____________________

Address: ________________________________________________________________

Brief description of the study:

______________________________________________________________________________
______________________________________________________________________________

Duration of study (start and end dates): _____________________________________________

Source of funding: ______________________________________________________________

List of documents submitted: (if there are more than 3 documents submitted, please use a
separate sheet. A soft copy of the list must also be provided):

Name:______________________ Date Submitted: _______________

Signature: __________________