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University of the East

College of Dentistry

REQUEST TO IMPLEMENT RESEARCH PROTOCOL

Working Title : _______________________________________________________________________________________________


_______________________________________________________________________________________________
Proponent/s : ___________________________ ____________________________ _____________________________
___________________________ ____________________________ _____________________________
This certifies that the above-mentioned research has been approved for implementation.
Adviser : ____________________________________________________ (Signature)________________________________
Research Professor : ____________________________________________________ (Signature)_________________________________
Procedures to be done:
USE OF UECD RESEARCH LABORATORY
Date & Time of Use : _______________________________________________________________________________________
Equipments / Instruments to be Used/Other particulars
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
USE OF OFF-CAMPUS FACILITIES
Name of Institution :________________________________________________________________________________________
Address : _____________________________________________________________________________________________________
Date & Time of Visit : _______________________________________________________________________________________
Contact Person & Contact Number : ______________________________________________________________________
Reason/s :____________________________________________________________________________________________________
Equipment / Instruments to be Used/Other particulars
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I/We, the students whose name/s appear/s above, pledge to abide by the rules and regulations of respective
institutions where the research will be conducted.I/We release the University of the East from any liability
arising from or maybe attributed tomy/our participation in this activity.

Conforme : ________________ ________________ ________________ ________________ ________________ ________________


Approved by :

MARIE GERTRUDE L. TUSCANO, DMD, MScD BLESILDA K. FORMANTES, DMD, MPH


Head, UECD Research Committee College Director for Research

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