HAYATABAD MEDICAL COMPLEX, PESHAWAR
FOR OFFICIAL USE
Manuscript No. /HEC/B&PSC/2021 Date of Receiving: ____/____/2022
__________________________________________________________________________
Title of Project: -
Principal Author: _______________________________.
Contact No: __________________________ Email: ________________________
Ethical Committee Observation:
Approved Signature Committee Members
Not Approved
Return with Remarks
Date:
FOR OFFICIAL USE
Manuscript No. ________________ Date of Receiving: -_______________.
________________________________________________________________________
GENERAL ETHICAL APPROVAL FORM
MTI/ HAYATABAD MEDICAL COMPLEX, PESHAWAR
CONFIDENTIAL
Important note: - This form should be completed and returned by email to Secretary
Institutional Ethics Committee at least eight weeks before the expected dated of execution of
the research project.
Please submit two har d copies as well, No application will be processed without a hard copy.
1. Title of the project
2. Name with contact info (Email/phone) of Principal investigator:
3. Name of Co-investigator(s)
4. Qualification of Principal investigator / Co-Investigator (s) if any:
5. Name of the Head of the Department
6. List any potential/approved funding and its sources to carry out the project?
7. Summary of the project including objectives and methods: please do not exceed 500
words/ a single page summary may be attached instead.
8. Will the project involve human subjects?
9. Will animals be used in the research project ? If yes, please give details .
10. Will the study involve special situations like involvement of children, pregnant women,
physical / mental handicap, prisoners and or any other vulnerable population? If yes,
please give details.
11. List the variables that will be included in the project using interview, clinical
examination, investigation, procedures or questionnaire etc.
12. What are the expected numbers of participant(s)/ subjects / cases?
13. What are proposed start and end dates of the project?
14. Will the participant (s) be compensated in any form including cash payment? If yes,
please give details.
15. Will you obtain the informed consent of the participant? If yes, what kind of consent
will you be taking? In case of written consent, please give details for adults or children
using: in case of verbal consent, indicate what you will include in your verbal consent:
16. Will the participants have the right to access their own information related to the
project for instance results of lab tests etc? if No. give reason / justification.
17. Is there any information that you would like to keep confidential from the participant?
If yes, please give reasons.
18. What steps will you take to keep the data confidential during and after the completion
of the project? Also indicate for how long would you keep the data?
19. Is there any potential harm to the study participants or patients? I f yes, what steps
would you take to minimize the harm?
20. Is there any potential benefit to the study participants or patients? If yes, please enlist /
describe.
21. How did you ensure that the potential benefits of your project outweigh the potential
harm? Please describe.
22. Is there any potential harm to yourself or other participating staff members? If yes,
what steps have been taken to minimize the harm?
23. Will there be any drugs and /or devices involved in the research? If yes would you
explain the potential risks and benefits to the patients?
24. Is there any potential environmental risk involved in the project ? If yes, what steps
would you take to minimize that?
25. Is there any conflict of interest at any stage of the project? (i.e including during the
project, dissemination stage, potential gains after completion of the project or any other
that you should mention prior to execution of the project) if yes, please give details.
26. Could the research project or part of the project in any way or at any stage create
conflict to the cultural norms or religious belief of the participants involved ? If yes,
what remedial steps will you take to minimize or eliminate such conflicts?
27. Is the research likely to have any negative impact on the reputation of the institution?
If yes, what steps would you take to minimize / eliminate such potential risks?
Important note:-please note that any change in the project for any reason, leading to any
modification in the project objectives/methods etc. shall be notified to eh IEC prior to project
execution on revised plan. In such cases resubmission for fresh ethical approval of the project
will be required.
The IEC shall be informed in writing if the project is discontinued for any reason, along with the
reasons of discontinuation.
In cases of joint venture with other organizations/institutions, ethical approval of the IEC of MTI/
Hayatabad Medical Complex, Peshawar will still be required, even if the IEC of the other
organization / institution has already granted ethical approval. Please attach a copy of the
ethical approval of the other organization.
Signature of Applicant Date:
Email address:
Prof. Dr. Wajid Ali Akhunzada
wajidpsy@hotmail.com.
