RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Mr. MOMIN SIRAJAHEMAD GULAMRAZAK,

M.Sc Nursing 1st year

Medical Surgical Nursing.

Year 2011-2012

PRAJWAL COLLEGE OF NURSING

BANGALORE-91
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

NAME OF THE Mr. MOMIN SIRAJAHEMAD GULAMRAZAK

1 CANDIDATE AND
ADDRESS Prajwal College of Nursing,
No.73/A, Balaji Layout, Byadarahalli,
Magadi Road, Bangalore-91

2 NAME OF THE
Prajwal College of Nursing
INSTITUTION
Bangalore-91

3 COURSE OF STUDY AND

I Year M.Sc., Nursing
SUBJECT
Medical Surgical Nursing.

4 DATE OF ADMISSION TO 31.10.2011

COURSE

5 TITLE OF THE TOPIC A study to assess the effectiveness of structured

teaching programme on knowledge regarding
emergency management of myocardial infarction
patient among fourth year B.Sc nursing students in
selected nursing colleges in Bangalore, Karnataka.
6. BRIEF RESUME OF THE INTENDED WORK:-

INTRODUCTION

Myocardial infarction, commonly known as a heart attack, is the irreversible

necrosis of heart muscle secondary to prolonged ischemia. This usually results from an
imbalance in oxygen supply and demand of the myocardium.1

Myocardial infarction (heart attack) is a serious result of coronary artery disease.

Coronary artery disease occurs from atherosclerosis, when arteries become narrow or
hardened due to cholesterol plaque build-up. Further narrowing may occur from thrombi
(blood clots) that form on the surfaces of plaques. Myocardial infarction occurs when a
coronary artery is so severely blocked that there is a significant reduction or break in the
blood supply, causing damage or death to a portion of the myocardium (heart muscle).
Depending on the extent of the heart muscle damage, the patient may experience
significant disability or die as a result of myocardial infarction1.

In addition to atherosclerosis, myocardial infarction may result from a temporary

contraction or spasm of a coronary artery. When this occurs, the artery narrows and the
blood flow from the artery is significantly reduced or stopped. Though the cause of
coronary artery spasm is still unknown, the condition can occur in both normal blood
vessels and those partially blocked by plaques1.

Emergency management of myocardial infarction is very necessary to avoid the

complications and recurrent attack. The advent of coronary care units and early
reperfusion therapy has substantially decreased in-hospital mortality rates and has
improved the outcome in survivors of the acute phase of MI. Complications of MI
include arrhythmic, mechanical, and inflammatory sequelae, as well as left ventricular
mural thrombus. In addition to these broad categories, right ventricular infarction and
cardiogenic shock are other possible complications of acute MI2.
6.1. NEED FOR THE STUDY

According to WHO study, smoking and heart disease has been well described in
populations all over the world. Twenty five year follow up of the Seven Countries Study,
reported a dose-dependent increase in risk of death. After 25 years, 57.7% of persons
smoking 30 cigarettes per day had died compared to only 36.3% of non-smokers.
Additional long-term data come from a 40 year follow up of British physicians which
noted that excess mortality from cardiovascular disease was two times higher among
smokers compared to non-smokers but that this ratio was even more extreme during
middle age4.

The data for men and women differ somewhat but recent work underlines the
importance of smoking as a cause of myocardial infarction in both men and women. As
an example, in a Norwegian study, rates of myocardial infarction were 4.6 times higher in
men than in women but rates among women who smoked were six times higher than non-
smokers and rates among men, three times higher than among nonsmokers 3. Danish
investigators concluded that women may be more sensitive to tobacco as risks of
myocardial infarction due to both current smoking and total tobacco exposure were
consistently higher in women than men, and higher for both groups than myocardial
infarction rates among non-smokers3.

A study was conducted on acute Chest Pain in the Emergency Room. Clinical and
laboratory data from 596 patients who came  to an emergency room complaining of chest
pain indicated that no single variable could identify low-risk patients as well  as a normal
ECG. A combination of three variables—sharp or stabbing pain, no history of angina or
myocardial infarction, and pain with pleurisy or positional components or pain that  was
reproduced by palpation of the chest wall—defined  a very-low-risk group in which ECGs
did not add accuracy to the evaluation and were potentially misleading; Standard cardiac
enzyme levels were of almost no use as an emergency room indicator  of myocardial
infarction. These findings emphasize the difficulty of identifying patients at low risk for
myocardial infarction or unstable angina in the emergency room without consideration  of
many factors from the history, the physical examination, and the ECG6.

Hence the investigator felt the need to conduct a study to evaluate the
effectiveness of structured teaching programme on student nurses knowledge regarding
emergency management of myocardial infarction.

6.2 REVIEW OF LITERATURE

Review of literature refers to the activities involved in identifying and searching

for information on a topic and developing a comprehensive picture of the state of
knowledge on that topic.

Review of literature helps the investigator to develop insight in the problem and
gain information about the problem and what has been done before. It provides basis for
future investigation, justifies the need for replication, throws light on the feasibility of the
study, constraints of data collection, and relates the findings from one study to another
with a hope to establish a comprehensive body of scientific knowledge and a professional
discipline from which valid and pertinent theories may be developed.

6.2.1 Reviews related to incidence of myocardial infarction.

6.2.2 Reviews related to prevention and control of myocardial infarction.
6.2.3 Reviews related to emergency management of myocardial infarction patient.
6.2.4 Reviews related to knowledge on management of myocardial infarction patient.

6.2.1 STUDIES RELATED TO INCIDENCE OF MYOCARDIAL INFARCTION.

A cohort study was conducted to find the trends in incidence and case fatality
rates of acute myocardial infarction in Denmark and Sweden. The Objective of the study
is to compare the incidence and case fatality of acute myocardial infarction in Denmark
and Sweden. All admissions and deaths with acute myocardial infarction as primary or
secondary diagnosis were extracted (Denmark, 1978 to 1998; Sweden, 1987 to 1999).
The incidence of myocardial infarction and the case fatality declined significantly among
all subgroups of patients. Case fatality was higher in Denmark early in the study period
(1987–1990) than in Sweden. The odds ratios (OR) ranged from 1.28 to 1.50 in the four
age groups. In 1994–1999, the prognosis of patients younger than 75 years did not differ.
Patients aged 75–94 years still fared worse in Denmark (OR 1.21, 95% confidence
interval 1.17 to 1.27). Women aged 30–54 years had a worse prognosis than men in both
Denmark and Sweden (OR associated with male sex 0.85 and 0.90, respectively). In
contrast, for patients older than 65 years, women had a better prognosis than men5.

A study was conducted on incidence, a simple risk score, and prognosis of

suboptimal coronary blood flow after primary per cutaneous coronary intervention for
acute myocardial infarction. The aim of the present study is to investigate incidence,
predictors, and long-term outcomes of suboptimal coronary flow after primary
percutaneous coronary intervention. A total of 2056 consecutive patients undergoing
primary PCI were retrospectively enrolled in the present study. Patients were grouped as
optimal [thrombolytic in myocardial infarction (TIMI) 3 flow, n=1939] and suboptimal
(TIMI≤2 flow, n=117) infarct-related artery at final coronary angiography after primary
PCI, and were followed for in-hospital and long-term outcomes for a mean period of
1.9±1.3 years (median of 22 months). Suboptimal coronary flow was observed in 5.7%
(n=117) of the patients. Four variables, selected from the multivariate analysis, were
weighted proportionally to their respective odds ratio for suboptimal coronary flow. The
suboptimal group had a higher prevalence of in-hospital mortality compared with the
optimal group (22.2 vs. 1.2%, respectively, P<0.001). Long-term cardiovascular mortality
was four-fold more in the suboptimal group than the optimal group (15.9 vs. 3.7%,
respectively, P<0.001)7.
6.2.2 STUDIES RELATED TO PREVENTION AND CONTROL OF
MYOCARDIAL INFARCTION.

A study was conducted on Early intervention and prevention of myocardial

infarction. Although there has been a decline in the incidence of ischemic heart disease in
Western Europe, North America and Australia/New Zealand. The interheart study
performed in 52 countries around the world has shown that the major risk factors are
tobacco smoking, elevated apolipoprotein A, hypertension, diabetes mellitus, abdominal
obesity, psychosocial factors, low fruit and vegetable intake, physical inactivity and
alcohol consumption. Primary prevention involves the avoidance of disease in high-risk
subjects free of disease, whereas the purpose of secondary prevention is to avoid
recurrence of myocardial infarction. Life-style measures (i.e. sensible diet, physical
exercise and smoking cessation) are effective and need to be promoted. Compliance with
preventive measures is achievable. Primordial prevention, which involves reducing the
prevalence of risk factors, rests mainly on public education, media, legislation and
government policy, and is very dependent on individual governments' commitment and
determination8.

6.2.3 STUDIES RELATED TO EMERGENCY MANAGEMENT OF

MYOCARDIAL INFARCTION PATIENT.
A study was conducted on acute coronary syndromes: consensus
recommendations for translating knowledge into action. Consensus recommendations
were based on evidence and expert opinion. Prompt reperfusion for patients with ST-
segment-elevation myocardial infarction should be ensured by establishing protocols for
single-call activation of primary percutaneous coronary intervention, or, where
unavailable, enabling health care workers to initiate thrombolytic. Accuracy of risk
stratification of non-ST-segment-elevation ACS (NSTEACS) should be improved using
clinical pathways that integrate ambulance, medical and nursing care. Rates of early
invasive management for patients with high-risk NSTEACS should be increased using
efficient systems for transfer to revascularization facilities. National standards for data
collection and clinical outcomes should be established, and performance should be
monitored9.
 A study was conducted on heterogeneity in the Management and Outcomes of
Patients with Acute Myocardial Infarction Complicated by Heart Failure. Heart failure
(HF) is an important predictor of poor outcome after acute myocardial infarction (AMI).
The objective of this study was to determine the clinical impact of HF complicating AMI
in the National Registry of Myocardial Infarction (NRMI). A secondary objective was to
determine differences in demographic and clinical characteristics, treatment, and hospital
death rates in patients presenting with HF compared with those developing HF after
presentation. The study sample consisted of 606500 patients with AMI and without a
history of HF included in the NRMI. Of 606 500 cases included from July 1, 1994 to
June 30, 2000, 123 938 (20.4%) patients had HF at the time of hospital presentation and
52 220 (8.6%) developed HF thereafter. Results from this nationwide registry suggest
that the incidence and hospital death rates associated with HF complicating AMI remain
high10.

6.2.4 STUDIES RELATED TO KNOWLEDGE ON MANAGEMENT OF

MYOCARDIAL INFARCTION PATIENT.

A study was conducted on Nurses' knowledge and skill retention following

cardiopulmonary resuscitation training: a review of the literature. This paper reports a
literature review examining factors that enhance retention of knowledge and skills during
and after resuscitation training. Papers published between 1992 and 2002 were obtained
and their reference lists scrutinized to identify secondary references, of these the ones
published within the same 10-year period were also included. One hundred and five
primary and 157 secondary references were identified. Of these, 24 met the criteria and
were included in the final literature sample. Four studies were found pertaining to cardiac
arrest simulation, three to peer tuition, four to video self-instruction, three to the use of
different resuscitation guidelines, three to computer-based learning programmes, two to
voice-activated manikins, two to automated external defibrillators, one to self-instruction,
one to gaming and the one to the use of action cards11.
 A study was conducted on home care nurses' knowledge of evidence-based
education topics for management of heart failure. The aim of the study is to evaluate
home care nurses' knowledge of evidence-based education topics in managing heart
failure (HF). Moreover, another aim is to determine if differences were evident in nurses'
knowledge based on education and work experience, and to identify home care nurses'
specific educational needs. Home care nurses' scores demonstrated a 78.9% knowledge
level in overall HF education principles. The mean HF knowledge score was 15.78 (SD,
±1.69) out of a possible 20 points. Nurses scored lowest on knowledge related to
asymptomatic hypotension (24.5% answered correctly), daily weight monitoring (26.6%
answered correctly), and transient dizziness (30.9% answered correctly). The results help
confirm the need to develop educational programs for home care nurses in managing HF,
which may lead to improved quality of patient education12.

A study was conducted on emergency nurses' knowledge of evidence-based

ischemic stroke care: a pilot study. The purpose of this pilot study was to assess
emergency nurses' knowledge of evidence-based ischemic stroke care. A descriptive, co
relational design was used. Test scores ranged from 30% to 90%, with a mean of 53%
(SD = 12.93) on a scale of 0 to 100%. Forty-five percent (N = 9) of respondents indicated
that they read literature on evidence-based ischemic stroke care within the previous 12
months. Respondents who read literature on evidence-based ischemic stroke care had a
significantly higher mean test score (P = .04) than did respondents who did not read any
literature on evidence-based ischemic stroke care. Only 15% (N = 3) of respondents
reported that they had participated in continuing education on evidence-based ischemic
stroke care within the previous 12 months13.

A study was conducted on nurses' knowledge of heart failure education topics as

reported in a small mid western community hospital. Recurrent heart failure (HF) is the
most common cause for readmission of elderly patients with HF. This study aims to
describe nurses' knowledge of HF self-management education principles. The mean (+/-
SD) HF self-care knowledge score was 14.6 +/- 2 (range = 9-19). There was no statistical
difference in mean score between intensive care unit (14.7 +/- 1.6) and floor (14.5 +/-
2.1) nurses. Correct responses to individual survey items ranged from 20% to 100%; 6
questions resulted in mean scores >90% correct, 9 questions had mean scores between
70% and 90% correct, and 5 questions had mean scores <70% correct. Most respondents
(90%) answered 6 questions correctly, but on 9 questions, 70% and 90% answered
correctly. On 5 questions, less than 70% answered them correctly. One suggested
intervention is to provide ongoing education for nurses regarding HF management14.

A study was conducted on nurses' knowledge of heart failure self-management.

This study assessed nurses' knowledge of basic principles of HF self-management. The
study surveyed 49 nurses who regularly provided care to patients with HF at a hospital in
the southeastern United States. A 20-item, true/false survey was administered to
participants. Mean HF self-management knowledge score was 15.97 (79.85% correct).
Consistent with previous studies, nurses scored lowest on knowledge related to transient
dizziness (16.3% answered correctly), daily weight monitoring (36.2% answered
correctly), and asymptomatic hypotension (58.3% answered correctly). Findings confirm
previous work suggesting that nurses may not be adequately prepared to educate patients
with HF about self-management15.

A study was conducted on Nurses' knowledge of heart failure education

principles. The aim of the study is to compare the psychometric properties of the original
dichotomously scored Nurses' Knowledge of Heart Failure Self-Management Education
Principles Survey with a likert scored version. This psychometric study had a two phase
non-experimental design comparing the psychometric characteristics of two versions of
an existing survey in addition to test-retest reliability of the revised survey. A
convenience sample of 122 nurses was recruited from a healthcare system located in the
Southeastern USA. The test-retest reliability of the Likert scored survey was r = 0·66.
Data from individual Likert scored items indicated nurses were most knowledgeable
about the need to continue daily weights even after HF symptoms are gone (mean = 4·43,
SD 0·51) and least knowledgeable about how to advise asymptomatic patients to manage
a low BP reading (mean = 2·11, SD 0·98)16.

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of structured teaching programme on

knowledge regarding emergency management of myocardial infarction patient among
fourth year BSc nursing students in selected nursing colleges in Bangalore.

6.3 OBJECTIVES OF THE STUDY

1. To assess the level of knowledge on emergency management of myocardial infarction

patient among fourth year BSc nursing students.
2. To assess the effectiveness of STP on emergency management of myocardial
infarction patient among fourth year BSc nursing students.

3. To find the association between the knowledge on emergency management of

myocardial infarction patient and selected demographic variables.

6.4 HYPOTHESIS

H1 -There will be statistically significance difference between pre-test and post-test

knowledge scores of BSc nursing students.
H2 –There will be significant association between knowledge score with selected
demographic variables.
6.5 OPERATIONAL DEFINITIONS

1. Effectiveness;-Refers to the significant improvement in the knowledge on

emergency management of myocardial infarction patient among fourth year BSc
nursing students after the structured teaching programme.
2. Structured teaching programme;- Refers to systemically planned group
instructions designed to provide information’s regarding emergency management
of myocardial infarction patient.
3. Emergency management;- Refers to all the immediate care which is required to
restore the myocardial blood flow in myocardial infarction patient.
4. Myocardial infarction;- Refers to Myocardial infarction (MI) commonly known
as a heart attack, results from the interruption of blood supply to a part of
the heart, causing heart cells to die.
5. MI patient; - Refers to those patients who have diagnosed with the disease
myocardial infarction.
6. Bsc nursing students;- Refers to those persons who are studying fourth year
BSC nursing in selected nursing colleges which is affiliated to Rajiv Gandhi
university of health sciences.

6.6 ASSUMPTIONS

1. BSc nursing students may have some knowledge about emergency management
of myocardial infarction patient.
2. Structured teaching programme will enhance the knowledge of BSc nursing
students regarding emergency management of myocardial infarction patient.

6.7 DELIMITATIONS

1. The study is limited to fourth year BSc nursing students only.

2. Data collection limited to selected colleges only.
7.0 MATERIALS AND METHODS

7.1 SOURSES OF DATA

Data will be collected from the fourth year BSc nursing students from selected
colleges in Bangalore.

7.2 METHOD OF DATA COLLECTION

7.2.1 REASEARCH DESIGN

Pre-experimental design. One group pre- test and post-test design

7.2.2 VARIABLES UNDER STUDY

Independent Variable

Structured teaching programme.

Dependent Variable

Knowledge on emergency management of myocardial infarction patient.

Demographic Variable
Age, sex, religion, type of family, socio-economic status and previous
information.

7.2.3 SETTING
The setting of study is selected nursing colleges in Bangalore.

7.2.5 SAMPLE
The purposed sample size of the study is 60.
7.2.6 SAMPLING TECHNIQUE

The sample technique will be adopted for the study is purposive sampling.

7.2.7 SAMPLE CRITERIA

Inclusion Criteria
1. Fourth year BSc nursing students who are willing to participate in this study.
2. Fourth year BSc nursing students who are present during the time of data
Collection.
Exclusion Criteria
1. Fourth year BSc nursing students who are not present during the time of data
Collection.
2. Fourth year BSc nursing students who undergone any teaching programme of
emergency management of myocardial infarction patient.

7.2.8 TOOLS OF REASEARCH

Section A – A structured questionnaire to assess demographic variables.

Section B - A structured questionnaire to assess the knowledge of fourth year

nursing students regarding emergency management of myocardial infarction
patient.

7.2.9 COLLECTION OF DATA

1. A prior formal permission will be obtained from the selected nursing colleges
authority for required information.
2. Informed consent will be obtained from the sample and assure them regarding
maintains privacy and confidentiality.
3. Structured questionnaire will be administered to assess the knowledge of
fourth year nursing students regarding emergency management of myocardial
infarction patient in terms of pre-test.
 4. Structured teaching programme will be given on emergency management of
myocardial infarction patient.
5. Structured questionnaire will be administered to assess the knowledge of fourth
year nursing students regarding emergency management of myocardial infarction
patient in terms of post test.
6. Duration of the study is 30 days.

7.2.10 METHODS OF DATA ANALYSIS AND PRESENTATION

-Investigator would analyze the data collected by using descriptive and inferential
statistics
-Assessing the knowledge of fourth year B.Sc nursing students will be interpreted by
descriptive statistics such as mean and standard deviation.
- Effectiveness of structured teaching programme will be analyzed by ‘t’test.
-Association between the knowledge of students on emergency management of
myocardial infarction patient with selected demographic variables is analyzed by chi
square(x2).

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN
OR ANIMALS? IF SO ,PLEASE DESCRIBE BRIEFLY

Yes, the study requires administration of structured questionnaire and structured

teaching programme to the fourth year BSc nursing students in selected nursing colleges.
This study is not harmful to the students.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION CASE OF 7.3?

Yes, informed consent will be obtained from the students. Privacy,

confidentiality and anonymity will be guarded. Scientific objectivity of the study will be
maintained with honesty and impartiality.
8. LIST OF REFERENCES:-
1. Available from the URL: http://emedicine.medscape.com/article/155919-overview.

2. Available from the URL: http://emedicine.medscape.com/article/164924-overview.

3. Available from the URL: http://www.imaginis.com/heart-attacks/heart-disease-

myocardial-infarction-heart-attack-1.

4. Available from the URL:

http://www.who.int/tobacco/research/heart_disease/en/index.html

5. S Z Abildstrom, S Rasmussen, M Rosén,M Madsen; Trends in incidence and case

fatality rates of acute myocardial infarction in Denmark and Sweden;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767620/.

6. Thomas H. Lee, MD; E. Francis Cook, ScD; Monica Weisberg, RN; R. Kent

Sargent, MD; Clyde Wilson, MD; Lee Goldman, MD; Acute Chest Pain in the
Emergency Room; Arch Intern Med. 1985;145(1):65-69.; http://archinte.ama-
assn.org/cgi/content/abstract/145/1/65.

7. Uyarel H, Ayhan E, Cicek G, Isik T, Ugur M, Bozbay M;Suboptimal coronary blood

flow after primary percutaneous coronary intervention for acute myocardial
infarction: incidence, a simple risk score, and prognosis; Coron Artery Dis. 2012
Mar;23(2):98-104; http://www.ncbi.nlm.nih.gov/pubmed/22318130.

8. Pais PS.; Early intervention and prevention of myocardial infarction; J Hypertens

Suppl. 2006 Apr;24(2):S25-30. http://www.ncbi.nlm.nih.gov/pubmed/16601557.

9. Brieger D, Kelly AM, Aroney C, Tideman P, Freedman SB, Chew D, Ilton

M, Carroll G et al; Acute coronary syndromes: consensus recommendations for
translating knowledge into action; Med J Aust. 2009 Sep 21;191(6):334-8;
http://www.ncbi.nlm.nih.gov/pubmed/19769557.
10. Frederick A. Spencer;Theo E. Meyer, Joel M. Gore; Robert J. Goldberg;
Heterogeneity in the Management and Outcomes of Patients With Acute Myocardial
Infarction Complicated by Heart Failure;
http://circ.ahajournals.org/content/105/22/2605.short.

11. Hamilton R.; Nurses' knowledge and skill retention following cardiopulmonary
resuscitation training: a review of the literature; J Adv Nurs. 2005 Aug;51(3):288-
97; http://www.ncbi.nlm.nih.gov/pubmed/16033596.

12. Delaney C, Apostolidis B, Lachapelle L, Fortinsky R; Home care nurses' knowledge

of evidence-based education topics for management of heart failure; Heart
Lung. 2011 Jul-Aug;40(4):285-92. Epub 2011 Mar 23;
http://www.ncbi.nlm.nih.gov/pubmed/21429581.

13. Harper JP; Emergency nurses' knowledge of evidence-based ischemic stroke care: a
pilot study;QM&I and Per Diem Clinical Educator, Taylor Hospital, Ridley Park,
PA, USA. harpjp2@verizon.net; http://www.ncbi.nlm.nih.gov/pubmed/17517264.

14. Washburn SC, Hornberger CA, Klutman A, Skinner L; Nurses' knowledge of heart

failure education topics as reported in a small midwestern community hospital; J
Cardiovasc Nurs. 2005 May-Jun;20(3):215-20;
http://www.ncbi.nlm.nih.gov/pubmed/15870593.

15. Willette EW, Surrells D, Davis LL, Bush CT; Nurses' knowledge of heart failure
self-management; Prog Cardiovasc Nurs. 2007 Fall;22(4):190-5;
http://www.ncbi.nlm.nih.gov/pubmed/18059195.

16. Hart PL, Spiva L, Kimble LP; Nurses' knowledge of heart failure education
principles survey: a psychometric study; J Clin Nurs. 2011 Nov;20(21-22):3020-8;
http://www.ncbi.nlm.nih.gov/pubmed/21615575.
9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF GUIDE

SIGNATURE

11.1 NAME AND DESIGNATION OF CO-GUIDE

SIGNATURE

11.2 HEAD OF THE DEPARTMENT

SIGNATURE

12. REMARKS OF THE PRINCIPAL

SIGNATURE