VERSION NO: 1

DR. JOSE FABELLA MEMORIAL

EFFECTIVE
HOSPITAL DATE:
FEB. 2, 2018

FORM 2.1
APPLICATION FOR INITIAL REVIEW
To be filled by investigator

REC Protocol
Number:

Sponsor Protocol
Submission Date:
Number:

Protocol Title:

Type of Research Clinical Clinical Trial Laboratory

Research Research

Genetic Sociobehavioral Public health

Research

Others: _________________________

Study Duration

Sponsor:

Principal
Investigator:

Telephone
Fax :
number:

E-mail: Preferred Phone Fax Email

means of
contact

Institution

Are you an employee of the sponsor? Yes No

Did you do consultancy or part time work
Yes No
for the sponsor?
In the past year, did you receive
Yes No
P250,000 or more from the sponsor?
Other ties with the sponsor:
 VERSION NO: 1

EFFECTIVE DATE:
DR. JOSE FABELLA MEMORIAL HOSPITAL FEB. 2, 2018

Ethical Responsibility and COI Statement

I hereby pledge to address all forms of COI that I may have and perform my
tasks objectively, protect the scientific integrity of the study, protect all human
participants and comply with my ethical responsibilities as Investigator.

PI Signature:

Documents submitted:
Protocol summary CVs
Patient information GCP certificates Received by REC
form Secretariat: (name)
Informed consent Study budget
form Date:
Advertisement Revised protocol
Investigator Revised consent
brochure form
Case report forms Amendments
(CRF)
Research team list Payment of fees
Others: