Komisi Etik – Fakultas Kedokteran

Medical and Health Research Ethics Committee
(MHREC)
Faculty of Medicine Universitas Gadjah Mada –
Dr. Sardjito General Hospital
SOP 4.1-012.2015-04

Effective date:

4.1. Review of Resubmitted Protocols

01 August 2015
Page 1 of 1

ANNEX 1
AF 4.1.01-012.2015-04
MEMORANDUM ADDRESSING CORRECTIONS
 2nd Review  3rd Review  4th Review

Protocol No.:
Protocol Title:
Principal Investigator:

Recommended revisions:

Tel.:
Revisions/ Modifications according to the
recommendation (add extra pages if necessary):

SIGNATURES:
Date:…………………
Principle Investigator
TYPE OF REVIEW:

ASSIGNED REVIEWERS:
1.



Exempted from review



Expedited Review

2.



Full Board Review

3.

Reviewer for informed consent documents:
COMPLETION:
Date:…………………
Secretary of MHREC-FM UGM