Komisi Etik – Fakultas Kedokteran Final Report FKUGM

Medical and Health Research Ethics Committee (MHREC)

Faculty of Medicine Universitas Gadjah Mada

SOP 4.4-015.2012-02 Effective date: 1 October 2012 Page 1 of 2 4.4. Review of Final Report

- ANNEX 1

AF 4.4.01-015.2012-02 page 1 of 2 Study Report Form

Protocol No.: Protocol Title :

Principal Investigator:

Phone number: E-mail address :

Sponsor’s Name

Address:

Phone : E-mail :

Study site(s):

Total Number of study participants : No. of Study Arms:

Number of participants who received the test articles:

Study materials:

Treatment form:

Study dose(s):

Medical and Health Research Ethics Committee (MHREC)

Faculty of Medicine Universitas Gadjah Mada

SOP 4.4-015.2012-02 Effective date: 1 October 2012 Page 2 of 2 4.4. Review of Final Report

ANNEX 1 AF 4.4.01-015.2012-02 page 2 of 2

Results:

(Use extra blank paper, if more space is required.)