website:

fk.maranatha. ETHIC COMMETTEE

edu/ethic FACULTY OF MEDICINE
MARANATHA CHRISTIAN UNIVERSITY -
IMMANUEL HOSPITAL BANDUNG
No Reg : 033/KNEPK/2008
Effective
Title: date:
Januari 2014
Final Report Form Page 1 of 2

Final Report Form

Protocol No.:
Protocol Title :

Principal Investigator:

Phone number: E-mail address :

Sponsors Name

Address:

Phone : E-mail :
Study site(s):
Total Number of study participants : No. of Study Arms:

Number of participants who received the test

articles:

Study materials:

Treatment form:

Study dose(s):

Duration of the study

Objectives:

Results:
(Use extra blank paper, if more
space is required.)

Signature of P.I.: Date:

File Name: Final Report Form for research using human subjects Ethic Committee Faculty of Medicine,
MCU-Immanuel Hospital
 website:
fk.maranatha. ETHIC COMMETTEE
edu/ethic FACULTY OF MEDICINE
MARANATHA CHRISTIAN UNIVERSITY -
IMMANUEL HOSPITAL BANDUNG
No Reg : 033/KNEPK/2008
Effective
Title: date:
Januari 2014
Final Report Form Page 2 of 2

File Name: Final Report Form for research using human subjects Ethic Committee Faculty of Medicine,
MCU-Immanuel Hospital