SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM DEPARTMENT OF EDUCATION AND RESEARCH
RESEARCH APPLICATION FORM
A. REQUESTOR INFORMATIONName :
NRIC /Passport No. : Staff/Student No. :
Email : Mobile No. :
Faculty/ Dept./
Institution :
Status : Principal Investigator (PI) / Co-Researcher/ Supervisor/ Co-Supervisor/ Research Assistant/
Student/ Other (Please specify) _________________________________________________
Category : IIUM Non-IIUM (To Specify)
Staff SASMEC @IIUM Student UG Student UG Other:
__________________
IIUM PG PG
_
B. RESEARCH INFORMATION Title of Research :
Type : * Please indicate (/) in appropriate column
Investigator Initiated Research (IIR)
Investigator Initiated Sponsored Research (IISR)
Industry Sponsored Research (ISR)
Funding
(Please Specify)
: Self Ministry Industry Other
Amount (Please specify) :
C. RESEARCHER (S) INFORMATION * Fill in which applicable
Principal Investigator
(If requestor is not a PI) :
Co-Researcher :
Supervisor
(If requestor is a student) :
Co-Supervisor :
D. RESEARCH AREA (S)/ VENUE (S) INFORMATION
Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur.
Tel: 09-591 2500
SASMEC-DEAR-CRC (GR)-F002 VER: 01 REV: 03 EFFECTIVE DATE: 20 SEPTEMBER 2022
IIUM-IIUMMC-F000 VER: 01 REV: 00
SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM DEPARTMENT OF EDUCATION AND RESEARCH
RESEARCH APPLICATION FORM
Departments/ Clinics/ Wards (Please specify) Start Date End Date
1) 2) 3)
E. RESEARCH SUPERVISOR (S) INFORMATION
*Please note that it is a requirement to have one SASMEC staff as a field supervisor from research site (research area/ venue)
Name Designation Departments/ Clinics/
Wards (Please specify) 1)
2) 3)
F. ACCESS TO I-PESAKIT DATABASE *If applicable
i-Pesakit access : No Yes (Please attach with i-Pesakit Access Form)
G. REQUESTOR’ S DECLARATION
I affirm that all the information given is correct. I am fully aware that the Sultan Ahmad Shah Medical Centre @IIUM reserves the right to reject this application or direct the applicant to leave the Sultan Ahmad Shah Medical Centre
@IIUM, if at any stage it is found that the information given is false.
REQUESTED BY:
………
(Signature and Stamp)
RECOMMENDED BY:
(SUPERVISOR/ PRINCIPAL INVESTIGATOR/HOD)
………..……….
(Signature and Stamp)
Name : ……… Name : ………
Position : ……… Position : ………
Date : ……… Date : ………
Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur.
Tel: 09-591 2500
SASMEC-DEAR-CRC (GR)-F002 VER: 01 REV: 03 EFFECTIVE DATE: 20 SEPTEMBER 2022
IIUM-IIUMMC-F000 VER: 01 REV: 00
