SAMAR STATE UNIVERSITY

Arteche Blvd., Catbalogan City, Philippines 6700

Office of the Vice President | Research & Extension Services

*please don’t change font-style and size. SSU-OVPRE-FR-023

04-FEB-2019 REV. 1

ETHICAL APPROVAL FORM

Application No.
Section 1: Applicant Details
Project Category: SSU Project Students PhD MS/M Personnel
A
External Client Students PhD MS/M Others
A
Researcher(s) Name Affiliation/Course
Name 1 Course
Name of Adviser (for student res.)
Email Mobile No.
Name 2 Course
Email Mobile No.
Name 3 Course
Email Mobile No.
Name 4 Course
Email Mobile No.
Name 5 Course
Email Mobile No.

Section 2. Research Details

Research Title
Proposed Start Date Expected Completion Date
Preliminary Ethical Animals Humans Data Plants
Flag(s)
Environment Others
Project Type Questionnaire/survey Experiments
Please mark the predominant Observational Data Based
nature of this project (select one
Others (define)
only)

Section 3. Purpose of the Project (Brief in form but comprehensive in scope/concise)

Section 4. Proposed Research Methods (Brief in form but comprehensive in scope/concise)

Section 5. Participants of the Study (Human subjects)

Number of Participants None
Exclusion Criteria (if applicable)
Inclusion Criteria (if applicable)

Additional Information
Yes No N/A
1. Will describe the main experimental procedures to participants in advance,
so that they are informed about what to expect?
2. Will you tell your participants that their participation is voluntary?
3. Will you obtain written consent for participation?
4. Will you explain to participants that refusal to participate in the study will
not affect their treatment or education (if relevant)?
5. With questionnaires, will you give participants the option of omitting
questions they do not want to answer?
6. Will you tell the participants that their data will be treated with full
confidentiality and that, if published, it will not be identifiable as theirs?

Telephone No. +6355 251 2139 | Fax: +6355 543 8394 | Website: www.ssu.edu.ph | Contact us: info@ssu.edu.ph | Follow us on @ssucatbalogan | Page 1 of 3
 SAMAR STATE UNIVERSITY
Arteche Blvd., Catbalogan City, Philippines 6700
Office of the Vice President | Research & Extension Services

SSU-OVPRE-FR-023
04-FEB-2019 REV. 1

7. Will you debrief participants at the end of their participation?

8. Do subjects/participants fall into any of the following special groups?
a. Children (under 18)
b. People with learning or communication difficulties
c. Patients
d. People in custody
e. People engaged in illegal activities
If you have ticked “NO” to any of Q1-8, please give an explanation in the box below

9. Will subjects/participants be paid?

10. Is electrical or other equipment to be used with subjects/participants?
11. Are there any financial or other interests to the researcher(s) or department
arising from this study?
12. Will your study involve deliberately misleading subjects/participants in
any way?
13. Is there any realistic risk of any subjects/participants experiencing either
physical or psychological distress or experiencing either physical or
psychological distress or discomfort?
If you have ticked “YES” to any of Q10-17, please give an explanation in the box below

Section 6. Research Locale (discuss in detail)

Section 7. Data Security, destruction, and data protection procedures (discuss in detail)

Section 8. Researcher’s Declaration:

I certify that the information contained in this application is accurate. I have acknowledged my
obligations and the rights of the participants. I confirm that the research will be conducted in line with all
the legal and ethical standards. I undertake to inform the committee of any changes to the protocol of the
staffing of this study.

Signature
Name Date

Signature
Name Date

Signature
Name Date

Signature
Name Date

Signature
Name Date

Signature &
Name of
Adviser Date
Section 9: Statement of Ethical Approval

The College recommends that the project/research be:

Approved with no changes Approval not required

Telephone No. +6355 251 2139 | Fax: +6355 543 8394 | Website: www.ssu.edu.ph | Contact us: info@ssu.edu.ph | Follow us on @ssucatbalogan | Page 2 of 3
 SAMAR STATE UNIVERSITY
Arteche Blvd., Catbalogan City, Philippines 6700
Office of the Vice President | Research & Extension Services

SSU-OVPRE-FR-023
04-FEB-2019 REV. 1

Pending approval (minor or major changes) Not Approved

Resubmit (address major issues)

Signature of College/
Campus Research Ethics Date
Representative

The Members of IERC recommends that the project/research be:

Approved with no changes (authorized for months

Pending approval (minor or major changes) Approval not required

Resubmit (address major issues) Not Approved

We the members of the SSU-IERC affirmed the decision by signing below

Signature
Name Date

Signature
Name Date

Signature
Name Date

Signature
Name Date

The Chair of IERC recommends that the project/research be:

Approved with no changes (authorized for months

Pending approval (minor or major changes) Approval not required

Resubmit (address major issues) Not Approved

Signature
Name Date

Certified by:

RHEAJANE AGUILAR- ROSALES, DM

(Chair, SSU- IERC) Date

Telephone No. +6355 251 2139 | Fax: +6355 543 8394 | Website: www.ssu.edu.ph | Contact us: info@ssu.edu.ph | Follow us on @ssucatbalogan | Page 3 of 3