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64 LAMPIRAN Lampiran 1
65 Lampiran 2
KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
KOMITE ETIK PENELITIAN KESEHATAN Sekretariat : Lantai 2 Gedung Laboratorium Terpadu
JL.PERINTIS KEMERDEKAAN KAMPUS TAMALANREA KM.10, Makassar. Telp.0411-5780103, Fax (0411) 581431.
Contact person dr. Agussalim Bukhari,M.Med,PhD,Sp.GK (HP. 081241850858), email: agussalimbukhari@ yahoo.com.
Lampiran 2
FORMULIR PERSETUJUAN SETELAH PENJELASAN (INFORMED CONSENT)
Saya yang bertandatangan di bawah ini :
Nama : ...
Umur : ...
Masa Kerja : ...
Satuan : ...
Alamat : ...
setelah mendengar/membaca dan mengerti penjelasan yang diberikan mengenai tujuan, manfaat, dan apa yang akan dilakukan pada penelitian ini, menyatakan setuju untuk ikut dalam penelitian ini secara sukarela tanpa paksaan.
Saya tahu bahwa keikutsertaan saya ini bersifat sukarela tanpa paksaan, sehingga saya bisa menolak ikut atau mengundurkan diri dari penelitian ini. Saya berhak bertanya atau meminta penjelasan pada peneliti bila masih ada hal yang belum jelas atau masih ada hal yang ingin saya ketahui tentang penelitian ini.
Saya percaya bahwa keamanan dan kerahasiaan data penelitian akan terjamin dan saya dengan ini menyetujui semua data saya yang dihasilkan pada penelitian ini untuk disajikan dalam bentuk lisan maupun tulisan.
Dengan membubuhkan tandatangan saya di bawah ini, saya menegaskan keikutsertaan saya secara sukarela dalam studi penelitian ini.
Nama Tanda tangan Tgl/Bln/Thn
Responden ……… ……….. ………..
/Wali
Saksi ……… ……….. ………..
66
(Tanda Tangan Saksi diperlukan hanya jika Partisipan tidak dapat memberikan consent/persetujuan sehingga menggunakan wali yang sah secara hukum, yaitu untuk partisipan berikut:
1. Berusia di bawah 18 tahun 2. Usia lanjut
3. Gangguan mental 4. Pasien tidak sadar
5. Dan lain-lain kondisi yang tidak memungkinkan memberikan persetujuan
Penanggung jawab penelitian : Identitas peneliti : dr. Andi Helgasari Nurlan
Alamat : BTP Jalan Tamalanrea Selatan 2D Blok M no.45 Telepon : 08124177912
67 LAMPIRAN 3
CURICULUM VITAE A. Data Pribadi
1. Nama : dr. Andi Helgasari Nurlan
2. Agama : Islam
3. Tempat/tanggal lahir : Palopo, 22 Agustus 1985
4. Alamat : BTP Jalan Tamalanrea Selatan 2D Blok M No.45 5. Nama Ayah/Ibu : Drs. Andi Nurlan Baslan, MM/ Sainur
6. Suami : dr. Jayarasti Kusumanegara, Sp.BTKV (K) B. Riwayat Pendidikan
1. SD : SDN 80 Lalebbata Palopo
2. SMP : SMP Negeri 1 Palopo
3. SMA : SMU Negeri 3 Palopo
4. Perguruan Tinggi : Fakultas Kedokteran Universitas Muslim Indonesia, Makassar, Angkatan tahun 2003 5. Profesi Dokter : Fakultas Kedokteran Universitas Muslim
Indonesia, Makassar, Angkatan tahun 2007 6. PPDS : Departemen Radiologi Fakultas Kedokteran
Universitas Hasanuddin Periode Januari 2019 C. Riwayat Pekerjaan : Pegawai Negeri Sipil Kota Palopo 2011 D. Makalah pada Seminar/ Konferens ilmiah Nasional dan Internasional :
“A Rare Case of 12 Years Old Boy With A Tricuspid Atresia, Pulmonary Atresia and Doble Outlet Right Ventricle”, dibawakan pada acara PIT PSRAI 31 Juli 2021
