مركز البحوث والدراسات التطبيقية / الموضوع /

نموذج طلب موافقة اللجنة المحلية لأخلاقيات البحث

Approval Request Application for Local Committee for Research Ethics
التاريخ

Researchers Information*

  1. Principle Investigator

Name / Qualification / College/Dept. / Academic Title / Phone / E-mail
  1. Co- Investigator(s)/Assistant

Name / Qualification / College/Dept. / Academic Title / Phone / E-mail

* Resume/CV of the PI and Co-Investigators/Assistants with emphasis on the research experience should be included with this application.

Research Proposal Title (not more than 120 letters)

Research Proposal Abstract (~ 300 words)

Research Proposal Description

  1. Research Problem:
  1. Research keywords:
  1. Research Significance/ Motivations:
  1. Research Objectives:
  1. Research Questions (if applicable):
  1. Literature Review:
  1. Research Methodology:
  1. Ethical Considerations:

Consider the following:
-balance the expected benefits and possible harms to which the human subject of the study may be subject to.
- Research location shall be appropriate to the assistant group, including available potentials and emergency measures.
-justify the use of any procedure/tool/machine that has not been used before in the research.
-justify the use of any dangerous/harmful substances/materials on the human subject of the study or the environment/community, and how the disposal of these substances/materials may be managed after research completion.
-plan to deal with dangerous cases.
-plan ofthe disposalof the biological samples/remains.
  1. Research Field:

Field / Description
( ) Medicine
( ) Allied Health
( ) Technology
( ) Others
  1. Describe how this research proposal serves the college and its mission:
  1. Research Total Period: () months
  1. Research Phases:

Phase / Duration / Description / Completion Indicator
1st
2nd
3rd
4th
  1. Research Team Responsibilities:

Investigator / Task Description
  1. Forms/Surveys to be Used*:

Form/Survey Name / Description / Target

* attach the forms/surveys to be used

  1. Study Samples*:

Sample / Property / Selection/Removal Criteria / Means of Selection/Communication

* you may attach additional description

  1. Individuals Eligible to Access Personal Data*:

Description of Individual / Type of Access

* For clinical research to access the medical records/ biological samples, etc. provide a description for the persons who may have such access

  1. Expected Results:

Expected Result / Means of Utilization
  1. Expected StartingDate://
  1. Tick if the proposed project is related to one of the following, and explain how:

( ) Supports one of the college projects, explain:
( ) Collaboration with another academic organization, explain:
( ) Collaboration with another industrial organization, explain:
  1. Who will benefit/optimize the expected results of this research proposal
  1. Please indicate if this research will lead to any of the following:

Item / Description / College Incentive
( ) Patent(s) Registration
( ) Commercial Product(s)
( ) Community Advancements
( ) Technology Transfer
( ) Publications
( ) Other Incentives
  1. Suggested Referees*

Name / Affiliation & Address / Contacts (phone, email, etc.)

* should provide at least 5 referees within the college or outside the college with no conflict of interests with the PI or/and other researchers within this or other research projects.

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