RESEARCH ETHICS COMMITTEE

RESEARCH APPLICATION FOR REC REVIEW

I. GENERAL INFORMATION
Development of a Web-based Barangay Management System with Community
TITLE OF STUDY Charge Sheet Hotspotting

REC CODE General Field

STUDY SITE
(To be provided by REC)
1. Alejo, Jewel Aldous II
N. TEL NO:
2. Carasig, Austin Jazz
NAME OF
INVESTIGATOR/S
0997-865-4263 (Alejo)
MOBILE NO:
0916-217-0166 (Carasig)

FAX NO:
CO- INVESTIGATOR/S
(If any)
EMAIL:

NAME OF INSTITUTION

INSTITUTION ADDRESS

□ Clinical Trial (Sponsored)

□ Biomedical Research (Retrospective,
□ Clinical Trials (Researcher-Initiated)
Prospective and Diagnostic Studies)
□ Health Operations Research
□ Stem Cell Research
(Health Programs and Policies)
TYPE OF STUDY □ Genetic Research
□ Social or Behavioral Research
□ Others: _______________________
□ Public Health or Epidemiologic

□ Multicenter
□ Multicenter (National) □ Single Site
(International)

□ Self-Funded
□ Sponsored by Pharmaceutical Company
□ Government-Funded
SOURCE OF FUNDING Specify: ______________________
□ Scholarship/Research Grant
□ Others: _______________________
□ Institution-Funded

F-REC-003 (10-25-19)
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 START DATE: NUMBER OF STUDY
DURATION OF STUDY
END DATE: PARTICIPANTS
HAS RESEARCH UNDERGONE TECHNICAL □ YES (Please attach
□ NO
REVIEW? technical review results)
HAS THE RESEARCH BEEN SUBMITTED TO
□ YES □ NO
ANOTHER RESEARCH ETHICS COMMITTEE?

II. BRIEF DESCRIPTION OF THE STUDY (Use additional sheet if necessary)

F-REC-003 (10-25-19)
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 III. CHECKLIST OF DOCUMENTS FOR SUBMISSION
BASIC REQUIREMENTS: SUPPLEMENTARY DOCUMENTS (If applicable):
□ Application for Thesis/Feasibility Study/Capstone □ Questionnaire
Project/Research Protocol Form (F-REC-001) □ Data Collection Forms
□ Research Proposal/Protocol Template □ Product Brochure
(F-REC-002) □ Philippine FDA Marketing Authorization or Import
□ Research Application for REC Review (F-REC-003) License
□ Protocol Assessment Form (F-REC-004) □ Permit(s) for special populations
□ Informed Consent to Participate in Research Form ____________________________
(F-REC-005) □ Others
□ Assent to Participate in Research Form ____________________________
(F-REC-006) (If applicable)
ACCOMPLISHED BY: DATE SUBMITTED:

Jewel Aldous N. Alejo II

Austin Jazz Carasig

_____________________________________________________________
(Signature over printed name)
---------- TO BE FILLED OUT BY THE REC SECRETARIAT ----------
□ Complete
COMPLETENESS OF DOCUMENT
□ Incomplete

REMARKS

DATE RECEIVED: (Place stamp here)

RECEIVED BY:

F-REC-003 (10-25-19)
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