Title Full name of PhD candidate Registration No.

-
Prof.
Dr.
Mr.
E-mail Mobile number
Ms.

Faculty registered under Department Institution

- -
Allied Health Sciences ABSMIDS
Biological Sciences KSHEMA
Dentistry
Date of provisional registration NGSIPS
Pharmacy NIA
Physiotherapy NICO
Medicine NIPT
Nursing NUCSER
NUINS
Category of admission

❍ Full-time with External fellowship

❍ Full-time with NU PhD Fellowship

❍ Full-time with JRF/SRF appointment in a project

❍ Full-time with no fellowship

❍ Part-time - In house
Provide details of Doctoral Committee
Name Designation Department Institution

Chairperson
(Guide)
Member 1

Member 2

Member 3

Member 4

Member 5

1. Title of project (No abbreviations, maximum 25 words)

2. Background and brief review of literature (maximum 1500 words )

3. Research questions / hypotheses (maximum 200 words)

4. Specific Objectives (maximum 100 words)

5. Materials and Methods (maximum 1200 words)

6. Significance of proposed study (Maximum 200 words)

7. References (Maximum 20, Vancouver style - numbered list in order of in-text citation )

8. Source(s) of support for budgetary requirements

❏ External research grant to Guide

❏ NU PhD Research Support Grant (NUFR3) to Guide

❏ From departmental / institution resources

❏ Self-funded by candidate

❏ Not Applicable - no financial resources required

Does your study involve... (tick whichever is applicable)

❏ Human subjects with therapeutic interventions

❏ Human subjects and / or collection of human biologicals samples BUT NO clinical intervention

❏ Use of human biological samples from repositories

❏ Non-human animal subjects / biological samples

❏ Use of microbiological material from non-human sources

Please respond to following questions with Yes or No
Yes No Not
Applicable
1A) Does your study involve a clinical intervention that is not a currently accepted standard intervention for the
condition? ❍ ❍ ❍
1B) If yes, are the risks associated with the proposed clinical intervention explained in the Participant Information
Sheet (PIS)? ❍ ❍ ❍
2A) Does you study involve withdrawal of standard therapy as part of research protocol?
❍ ❍ ❍
2B) If Yes, is this explicitly stated in the Participant Information Sheet (PIS)?
❍ ❍ ❍
3A) Does your study involve randomisation of study participants to intervention groups?
❍ ❍ ❍
3B) Is the randomisation aspect of the study explicitly stated in the Participant Information Sheet (PIS)?
❍ ❍ ❍
4A) Does your study involve any non-therapeutic physical / pharmacological or psychological intervention /
manipulation for purpose of research? ❍ ❍ ❍
4B) Is the nature of such physical / pharmacological / psychological intervention / manipulation and possible risks
stated clearly in the Participant Information Sheet (PIS)? ❍ ❍ ❍
5A) Does your study involve collecting of human biological samples for research
❍ ❍ ❍
5B) Is the purpose of collection of biological samples explicitly stated in the Participant Information Sheet (PIS)?
❍ ❍ ❍
6A) Does your study involve any invasive procedures?
❍ ❍ ❍
6B) If Yes, are the possible risks associated with the invasive procedures
❍ ❍ ❍
7A) Does your study involve exposure of study participants to any type of radiation / radio-active material?
❍ ❍ ❍
7B) Is the exposure to radiation and associated risks explicitly stated in the Participant Information Sheet (PIS)?
❍ ❍ ❍
8) Are the confidentiality terms explained in the Participant Information Sheet (PIS)
❍ ❍ ❍
9) Is the participant's right to withdraw from study without prejudice to medical care stated in the Participant
Information Sheet (PIS)and Informed Consent Form? ❍ ❍ ❍
10) Is the Participant Information Sheet (PIS)and Informed Consent Form available in local language(s)
❍ ❍ ❍

Justify the use of proposed clinical intervention and / or withdrawal of standard therapy in the study and
comment on it's safety (maximum 300 words). Enter NA if not applicable.

Justify the use of proposed physical / pharmacological / psychological manipulation in the study and
comment on it's safety (maximum 300 words).

Justify the use of proposed invasive methods (if any) in the study and comment on it's safety (maximum
300 words). Enter NA if not applicable.
Justify the exposure of study participants to to radiation / radio-active material (if any) in the study and
comment on it's safety (maximum 300 words). Enter NA if not applicable.

Does the Chairperson of the Doctoral committee hold an appropriate medical / dental qualification
(MD/MS/MDS)
❍ Yes ❍ No

Does at least one member of the Doctoral committee hold an appropriate medical / dental qualification
MD/MS/MDS)
❍ Yes ❍ No

Is your study registered in the Clinical Trials Registry of India? (See

http://ctri.nic.in/Clinicaltrials/login.php for details)
❍ Yes, registered.

❍ To be registered.
❍ No, will not be registered.

Have you received appropriate Institutional authorization for use of archival / repository samples?

❍ Yes
❍ Applied, awaiting approval
❍ No

Have you received approval Letter from Institution Animal Ethics Committee?

❍ Yes

❍ Applied, awaiting approval

Explain bio-safety issues and measures to minimize risk if any (maximum 300 words)
Does your study involve use of any recombinant technology and / or molecular cloning?

❍ Yes
❍ No

Any other regulatory issues anticipated requiring special review / clearance?

❍ Yes
❍ No

Regulatory issues - details

Source of financial support

Are you ready to submit the form?

❍ YES, I wish to submit now.

❍ NO, I wish to save and resume later.

Save and Resume Later

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