Colegio San Agustin – Bacolod REC Form: 2 – 01

Research Ethics Committee Forms Page 1 of 1

Version No.: 02
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:

REC Form 2 - 01 - SUBMISSION CHECKLIST FOR REC REVIEW

RESEARCH PROTOCOL CODE: _ ( to be filled out by the REC)

RESEARCH TITLE:
__________________________________________________________________
__________________________________________________________________

RESEARCH PROPONENT
Name: ______________________________________________Contact No.: ____________________________

CO-RESEARCHERS
Name: ___________________ Contact No.: ___________________________________

Name_____________________________ Contact No.: ___________________________________

Name:_________________ Contact No.: __________________________________

*Continue at the back of the research project team involves more than 4 researchers

Checklist: (All documents are to be submitted as PDF File)

_ REC Form 2 - 01 - Submission Checklist for REC Review
__________ REC Form 2 - 02 - Application Form for REC Review
_ Curriculum Vitae of Research Proponent and Co-Researchers
_ Research Protocol
_ Informed Consent Form
Budget (for funded research only)
_ Gantt Chart (for funded research only)
_ Endorsement Letter from the Research Adviser signed by the Technical Panel & REC
Primary Reviewer
(note: Remove REC Primary Reviewer if no REC representative is present during the
proposal defense.)

Submitted by:

Date: ___________________

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 Colegio San Agustin – Bacolod REC Form: 2 – 02
Research Ethics Committee Forms Page 1 of 7
Version No.: 01
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:
Signature over Printed Name (mm/dd/yyyy)

I.
I.
GENERAL INFORMATION

RESEARCH PROTOCOL REC Form 2 - 02

CODE: - APPLICATION FORM FOR REC REVIEW
__________________________________________________________________________
For Initial Review and Resubmission
RESEARCH TITLE:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

DURATION OF THE RESEARCH: _______________

RESEARCH PROPONENT:
Name: _______________________________________________________________________________________
Contact Information:
Tel No.: Mobile No.:___________________________ Email: ___________________________
CO-RESEARCHERS
Name:____________________________________________________________________________________________
Contact Information:
Tel No.: Mobile No_________________________________ Email: ___________________________

Name: __________________________________________________________________________________________
Contact Information:
Tel No.: Mobile No_________________________ Email: ___________________________________

Name:_________________________________________________________________________________________
Contact Information:
Tel No.: Mobile No_________________________ Email: ___ ________________________________

TYPE OF SUBMISSION
Initial Review
£ Resubmission (includes protocol revisions / responses based on initial review
recommendations or submission of studies with investigator-initiated changes
prior to ethics approval)

DATE OF SUBMISSION: __________________________________________

(mm/dd/yyyy)

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 Colegio San Agustin – Bacolod REC Form: 2 – 02
Research Ethics Committee Forms Page 3 of 7
Version No.: 01
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:

REC Form 2 - 02 - APPLICATION FORM FOR REC REVIEW

For Initial Review and Resubmission

RESEARCHER CATEGORY
□ CSA-B Administrator/Faculty/Academic Non-Teaching Personnel
□ CSA-B Students
□ External Researchers: Administrator/Faculty/Staff
□ External Researchers: Students
RESEARCH CATEGORY
□ Research involving human participants
□ Research involving animals (specify):
□ Others (specify):
TYPE OF RESEARCH
□ Basic Research
□ Applied Research
□ Outcomes-Based Research and Development
SOURCE OF FUNDING
□ Institutionally Funded
□ Externally Funded
□ Not Applicable

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 Colegio San Agustin – Bacolod REC Form: 2 – 02
Research Ethics Committee Forms Page 4 of 7
Version No.: 01
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:

REC Form 2 - 02 - APPLICATION FORM FOR REC REVIEW

For Initial Review and Resubmission

ETHICAL CONSIDERATIONS
Please indicate the page (pp.) and paragraph (par.) in the research protocol that contains
the following information AS APPLICABLE:
a. Protection of privacy and confidentiality of research information including data
protection plan __________________________________________________________________
b. Vulnerability of research participants __________________________________________
c. Risks of the study (including social risks)
d. Benefits of the study _________
e. Participant-related reimbursements/ incentives _________________________________________
f. Informed consent process and recruitment procedures ________________________________
g. Terms of reference of collaborative study (as applicable, such as intellectual
property agreements and similar concerns)
_________________________________________________________

USE OF SPECIAL POPULATIONS OR VULNERABLE GROUPS

□ Children (under 18)
□ Indigenous People
□ Elderly
□ People on welfare/social assistance
□ Poor and unemployed
□ Patients in emergency care
□ Homeless persons
□ Refugees or displaced persons
□ Patients with incurable diseases
□ Others (specify): _

ENDORSING DEPARTMENT/ COLLEGE/ UNIT/ INSTITUTION

□ Basic Education Department (BED)
□ College of Accountancy, Business Education and Computer Studies
(CABECS)
□ College of Arts, Sciences, and Education (CASE)
□ College of Engineering (COE)
□ College of Health and Allied Professions (CHAP)
□ Academic Non-Teaching Personnel (specify unit):
□ CSA-B Administration
□ External Institution (specify):

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 Colegio San Agustin – Bacolod REC Form: 2 – 02
Research Ethics Committee Forms Page 5 of 7
Version No.: 01
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:

REC Form 2 - 02 - APPLICATION FORM FOR REC REVIEW

For Initial Review and Resubmission

RESEARCH SITE:

__________________________________________

RESEARCH SITE ADDRESS:

________________________________

RESEARCH SITE CONTACT PERSON:

Name: ____________________________________
Contact Information:
Tel No.: Mobile No.: Email: _

FUNDING AGENCY (if applicable)

Name of Institution: _________________________________________________________________________________
Address: ______________________________________________________________________________________________
_________________________________________________________________________________________________________

AMOUNT OF RESEARCH FUND (if applicable):__________________________________________________

DECLARATION OF CONFLICT OF INTEREST OF THE RESEARCH PROPONENT

□ I have no conflict of interest in any form (financial, proprietary, professional) with funding
agency, co-researchers, or the site
□ I have personal/family financial interest in the results of the study
Specify:
□ I have proprietary interest in the research for which this application is being
made (patent, trademark, copyright, licensing)
Specify _________________________________________________________________________
□ Others (specify):

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 Colegio San Agustin – Bacolod REC Form: 2 – 02
Research Ethics Committee Forms Page 6 of 7
Version No.: 01
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:

REC Form 2 - 02 - APPLICATION FORM FOR REC REVIEW

For Initial Review and Resubmission

II. INFORMATION FOR ETHICS REVIEW

Expected Outcomes of the Study:
___________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Dissemination of Results and Publication Policy:

_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Safety Considerations:

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Follow up of Participants:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

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 Colegio San Agustin – Bacolod REC Form: 2 – 02
Research Ethics Committee Forms Page 7 of 7
Version No.: 01
2 - MANAGEMENT OF INITIAL SUBMISSIONS
Approval Date:
AND RESUBMISSIONS
Effective Date:

REC Form 2 - 02 - APPLICATION FORM FOR REC REVIEW

For Initial Review and Resubmission
___________________________________________________________________________________________________________

INFORMATION FOR ETHICS REVIEW

Problems Anticipated:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Ethical Considerations:
___________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please take note that this form is to be submitted together with REC Form 2-01 –
Submission Checklist for Ethics Review