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  Lampiran 1.

  

PENJELASAN MENGENAI PENELITIAN :

  LEMBAR PENJELASAN KEPADA CALON SUBJEK PENELITIAN Selamat pagi/siang Ibu/Saudari sekalian Nama saya dr. Surjadi Rimbun dan akan melakukan penelitian dengan judul:

  

Ekspresi m-RNA mammaglobin pada wanita penderitaa kanker payudara

dengan metastase di Kotamadya medan . Penelitian ini bertujuan untuk mengetahui

  Ekspresi m-RNA mammaglobin. Dengan diketahuinya ekspresi m-RNA mammaglobin maka diharapkan akan dapat menambah modalitas terapi terhadap kanker payudara. Jika Ibu/Saudari bersedia mengikuti penelitian ini maka akan dilakukan pemeriksaan terhadap Ibu/Saudari dengan cara melakukan wawancara, pengambilan darah vena daerah cubiti/ siku untuk diperiksa di laboratorium.Kami sangat mengharapkan keikut sertaan Ibu/Saudari dalam penelitian ini, karena selain bermanfaat untuk diri sendiri, juga bermanfaat untuk orang lain. Selama penelitian ini, Ibu/Saudari tidak dibebankan biaya apapun. Semua data/keterangan dari Ibu/Saudari bersifat rahasia, tidak diketahui orang lain. Apabila keberatan, Ibu/Saudari bebas untuk menolak mengikuti penelitian ini, tanpa khawatir akan mengurangi pelayanan yang kami berikan.

  Jika sudah mengerti dan bersedia mengikuti penelitian ini maka Ibu/saudari dapat mengisi lembar persetujuan. Pemeriksaan yang akan dilakukan diatas pada lazimnya tidak akan menimbulkan hal yang berbahaya bagi Ibu/Saudari sekalian, Namun bila terjadi hal-hal yang tidak diinginkan yang disebabkan oleh perlakuan penelitian ini, maka Ibu/Saudari dapat menghubungi saya. Nama : dr. Surjadi Rimbun Alamat kantor : Jl. Krakatau 57-C Medan (telp-HP 0616614923-0811632515) Demikian penjelasan ini saya sampaikan, kiranya hasil dari penelitian ini bermanfaat bagi kita semua.

  Medan, Oktober 2012...... Peneliti, (dr. Surjadi Rimbun)

  Lampiran 2.

  

LEMBAR PERSETUJUAN SETELAH PENJELASAN

(INFORMED CONSENT)

Saya yang bertanda tangan dibawah ini: Nama :

  Umur : Jenis kelamin : Alamat : No.Telp./ HP : Setelah mempelajari dan mendapatkan penjelasan yang sejelas-jelasnya mengenai

penelitian yang berjudul Ekspresi m-RNA mammaglobin pada wanita penderita Kanker

payudara dengan metastase di Kotamadya Medan, dan setelah mengetahui dan menyadari

sepenuhnya risiko yang mungkin terjadi, dengan ini saya menyatakan bahwa saya bersedia

dengan sukarela menjadi subjek penelitian tersebut dan patuh akan ketentuan-ketentuan yang

dibuat peneliti. Jika sewaktu-waktu ingin berhenti, saya berhak untuk tidak melanjutkan mengikuti penelitian ini tanpa ada sanksi apapun. Yang menyatakan Saksi ( ) ( )

  Peneliti

(Dr. Surjadi Rimbun)

  Lampiran 3. Kuesioner subjek DATA SUBJEK

  INISIAL SUBJEK

  : ░░░░░░░░ Nama : ...................................................................... Jenis kelamin : P Umur : ....... tahun ; Tanggal lahir : ..........................

  Pekerjaan : ……………………………………………….. Alamat : ......................................................................... Telp. : ............................ HP : .................................. Tempat/ tgl : Medan,/ .............. ..........................................

  1. Apakah Ibu/saudari sekarang ini sedang menderita penyakit kanker

  payudara ?

  ฀ YA ฀ TIDAK

  2. Jika YA,apakah Ibu/saudari sedang dalam masa pengobatan kanker

  payudara?

  ฀ YA ฀ TIDAK Jika YA, apa jenis pengobatan yang sedang berjalan sekarang?

  ฀ Operasi ฀ Radiasi ฀ Kemoterapi

  3. Jika TIDAK, apakah Ibu/saudari sudah selesai menjalani terapi lebih dari 5 tahun? ฀ YA ฀ TIDAK

  4. Jika TIDAK, apakah ini kanker yang kambuh kembali menurut dokter yang merawat Ibu/ saudari? ฀ YA ฀ TIDAK

  5. Apakah Ibu/saudari selama masa pengobatan, rutin menjalani pemeriksaan darah? YA TIDAK

  ฀ ฀

  Jika YA, pemeriksaan darah rutin apa yang pernah atau sedang dijalani? …………………………………………………………………………………… …..................................................................................................................

  .........................................................................................................................

  6. Apakah dokter yang merawat pernah memberitahukan keadaan penyakit

   kanker payudara Ibu/ saudari?

  ฀ YA ฀ TIDAK

  7. Jika YA, apakah Ibu/ saudari tahu tentang stadium penyakit kanker ?

   payudara

  ฀ YA ฀ TIDAK

  8. Apakah juga Ibu/ saudari tahu tentang stadium penyakit kanker payudara yang sedang/ pernah diderita?

  ฀ YA

  ฀ TIDAK

  9. Stadium penyakit kanker payudara adalah : (beri tanda

   pada bagian yang dirasa benar, jawaban boleh lebih dari satu)

  ฀ Stadium dini adalah bila kanker hanya mengenai salah satu payudara ฀ Stadium dini adalah bila kanker masih dapat diobati ฀ Stadium terdiri dari I sampai IV ฀ Stadium lanjut adalah bila kanker telah menyebar ke organ lain (metastase) ฀ Stadium lanjut sama dengan stadium IV

  Lampiran 4. Data Klinis dan histopatologi serta hasil imaging penderita kanker payudara DATA SUBJEK

  INISIAL SUBJEK

  : ░░░░░░░░ Nama

  : …. ............................................................. Jenis kelamin : P Umur : ....

  …. tahun ; Tanggal lahir : ...................... ….

Pekerjaan : ………………………………………………..

  Alamat : ......................................................................... . Telp. : ............................ HP : ............................... .... Tempat/ tgl : Medan,/ ...................................................... .... No. Med Rekod : ..........................................................................

  1. Diagnosa klinis : ……………………………………………………......

  2. Hasil Histopatologi :………………………………………………………….

  3. Hasil Foto X-Ray :………………………………………………………….

  4. Hasil USG :………………………………………………………….

  5. Hasil CT-Scan :…………………………………………………………..

  6. Hasil MRI/PET CT :…………………………………………………………..