Research Ethics Committee of

National Bioethics Committee

Government of Pakistan

Ministry of National Health Services, Regulations and Coordination

Islamabad

REC Application Form for Exemption of Studies from Ethical Review

Secretariat

Pakistan Health Research Council

Shahrah-e-Jamhuriat, off Constitution Avenue

Sector G-5/ 2

Islamabad

Adapted & Used with Thanks & Permission of Aga Khan University Ethics Review Committee

Research Ethics Committee of National Bioethics Committee

Government of Pakistan

Ministry of National Health Services, Regulations and Coordination

1. Study Title

2. Principal Investigator	Name	Department
3. Co-PI's	Names	Department
4. Signature of PI

Please mark the appropriate box as √

5. Types of study	Yes	No
a.	Retrospective review of patient's charts/routine collected data
b.	Prospective data collection from patient's charts
c.	Analysis of laboratory/ radiology data
d.	Clinical audit
e.	Evaluation of practice guidelines
f.	Case reports
g.	Others; please specify
6. Period of data collection
From
7. Starting date of study

8. Summary of data to be collected	Yes	No
a.	Demographics of the patients i.e. name addresses, phone numbers, e-mail address
b.	Clinical notes
c.	Photographs
d.	Laboratory data/ radiology data
e.	Management data
f.	Other, please specify

9. Utilization of data to be collected: Will it be used for	Yes	No
a.	Publication of papers in journals / newspapers
b.	Oral / poster presentation in meetings / conferences
c.	Students / residents’ teaching
d.	Planning subsequent larger studies

10. Summary of Objectives & Methods of Study including selection and exclusion criteria of study subjects, sample size, analysis plan etc.

1. Aim and Objectives:

2. Study design: \

.

3. Study population:

4. Data Sources and Variables:

5. Analysis and Statistics:

11. Please answer the following questions and mark the appropriate box as √

Yes	No
a.	Will any photographs be used/taken for publication?
b.	If yes, has written permission been obtained from study subject or guardian?
c.	Is there any ethical concern/issue?
d.	If yes, what were the ethical issues?
e.	Were those ethical concerns resolved?

Page-1/6

_____________________________________________________________________________________________________________

NBC Secretariat: Pakistan Health Research Council, Shahrah-e- Jamhuriat, Off Constitution Avenue, Sector G-5/2, Islamabad.

www.nbcpakistan.org.pk, email: nbcpakistan,org@gmail.com, Tel: +92-51-9224325, 9216793, Fax: 051-9216774

ETHICS REVIEW COMMITTEE

ASAD JAMIL RAJA

2017-05-31

khalid

MSF OCB