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1
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2
 Department of Community Ophthalmology, BSMMU

Patient ID No:

অবহিতক্রমে সম্মতিপত্র
(INFORMED CONSENT FORM)

Name of investigator: Dr. Nazia Ahmed Himi

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3
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4
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5
(D) Ocular examination:

Visual acuity R/E L/E

Unaided
PH
Aided
BCVA

Slit lamp examination R/E L/E

Eyelashes

Eyelids

Conjunctiva

Cornea

Anterior chamber
Iris and pupil
Lens
Fundus
IOP

Checked by-- Done by--

7.5 Detailed Budget:

6
Sl no Expense item Quantity Unit Total remarks
Cost (BD TK)
1 Instrument cost

a Pen Torch 2 1000 2000

Subtotal (1) 2000

2 Tools & materials

a Pen & notepad 50 28 1400

b File 10 40 400

c A4 paper 4 400 1600

d Ink cartridge 2 1300 2600

e Photocopy 30000

f Binding & compose 15000

Subtotal (2) 51000

3 Data analysis (3) 25000

4 Miscellaneous 15000
expenditure (4)
Grand total (1+2+3+4) 93,000