Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
ETHICS REVIEW COMMITTEE
DOCUMENT RECEIPT FORM
Received Number:ERC Protocol Number: / Date (D/M/Y):
Type of Submission: / Initial Review
Resubmission for re-review
Protocol Amendments / Continuing Review
Protocol Termination
Final Report
Protocol Title:
Principal Investigator/s:
Delivery route: / Post / E-submission / In Person
Documents Submitted: / complete / incomplete, will submit on:
Documents to be submitted later: / CV with 2 x 2 picture of PI and Co-Investigator/s
ERC Application For Protocol Review
Protocol Summary Sheet
(Hard Copy) ____ copies
Protocol Summary Sheet
(Soft Copy – MSWord Format)
Complete Research Protocol
(Hard Copy) ____ copies
Complete Research Protocol
(Soft Copy – PDF Format)
Study Budget
Technical Review Board Approval
Informed Consent Form
___ English Version
___ Tagalog Version
___ Ilocano Version
Patient Information Form
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Investigatory Brochure
Case Report Form (CRF)
Research Team List
GCP Certificates
Information for Subjects
Revised Protocol*
Revised Consent Form*
Review of Resubmitted Protocol*
(Hard Copy) ____ copies
(Soft Copy – MSWord Format)
Amendments*
Others: / Check what documents are received later on.
CV with 2 x 2 picture of PI and Co-Investigator/s
ERC Application For Protocol Review
Protocol Summary Sheet
(Hard Copy) ____ copies
Protocol Summary Sheet
(Soft Copy – MSWord Format)
Complete Research Protocol
(Hard Copy) ____ copies
Complete Research Protocol
(Soft Copy – PDF Format)
Study Budget
Technical Review Board Approval
Informed Consent Form
___ English Version
___ Tagalog Version
___ Ilocano Version
Patient Information Form
Advertisement
Investigatory Brochure
Case Report Form (CRF)
Research Team List
GCP Certificates
Information for Subjects
Revised Protocol*
Revised Consent Form*
Review of Resubmitted Protocol*
(Hard Copy) ____ copies
(Soft Copy – MSWord Format)
Amendments*
Others:
Date:
Received by:
Date Received:
Please bring this receipt with you when contacting or arranging an appointment with the BGHMC ERC.
PRIMARY INVESTIGATOR PROFILELast Name: / First Name:
Middle Name: / Mobile Number:
Home Address:
Email Address: / PRC License No.:
Profession: / Expiration Date:
Department: / Title:
Institution:
Office Address:
Office Number: / Email Address:
Sponsor/s:
Do you have a GCP Certificate? / __ YES __ NO, if YES, Expiration Date:
Study Site in Hospital (if any):
Study Site Contact No.: / Site Email:
Site Visit Date: / (to be filled-out by ERC Secretariat)
CONTACT US
BGHMC Ethics Review Committee
1stFloor Main Building
Baguio General Hospital and Medical Center
Governor Pack Road, Baguio City 2600
Work Hours: Tuesdays and Thursdays
10:00am – 12:00nn only
Email:
Website: go to ERC
Landline: (074) 661-7949 loc 218
Page 1 of 2 BGHMC-ERC-Form-02-005 Rev.1