Komisi Etik – Fakultas Kedokteran Final Report FKUGM

Medical and Health Research Ethics Committee SOP 4.4-015.2012-02
(MHREC)
Effective date:
Faculty of Medicine Universitas Gadjah Mada

1 October 2012
Page 1 of 2

4.4. Review of Final Report

- ANNEX 1
AF 4.4.01-015.2012-02
page 1 of 2
Study Report Form
Protocol No.:
Protocol Title :
Principal Investigator:
Phone number:
Sponsor’s Name

E-mail address :

Address:
Phone :
Study site(s):
Total Number of study participants :
Number of participants who received the test
articles:
Study materials:

Treatment form:
Study dose(s):
Duration of the study
Objectives:

E-mail :

No. of Study Arms:

Medical and Health Research Ethics Committee SOP 4.4-015.2012-02
(MHREC)

Effective date:
Faculty of Medicine Universitas Gadjah Mada

1 October 2012
Page 2 of 2

4.4. Review of Final Report

ANNEX 1
AF 4.4.01-015.2012-02
page 2 of 2
Results:
(Use extra blank paper,
if more space is
required.)

Signature of P.I.:

Date: