SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM DEPARTMENT OF EDUCATION AND RESEARCH
iPESAKIT ACCESS FORM
Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur.
Tel: 09-591 2500
SASMEC-DEAR(G)-F002 VER: 01 REV: 04 EFFECTIVE DATE: 01 SEPTEMBER 2022
A. DETAILS OF APPLICANT
Name Of Requestor : _______________________________________________________________________
Faculty/Institution : _____________________________ NRIC No. : _________________________
Email : ___________________________ Mobile No. : _________________________
Type Of Program : Elective Placement Research Training
(If () Research, Please _______________________________________________________________________________________
State Title Of Research) _______________________________________________________________________________________
_______________________________________________________________________________________
Venue/Site/Location : 1) ____________________________________________________________________________________
2) _____________________________________________________________________________________
3) _____________________________________________________________________________________
Start Date : _______________________________ End Date : __________________
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Signature Applicant Date : ___________________
B. HEAD OF DEPARTMENT/SUPERVISOR
Recommended Not Recommended Justification if the application is not recommended:
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________
Signature Date : __________________
C. HEAD EDUCATION AND RESEARCH
Recommended Not Recommended
Justification if the application is not recommended:
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________
Signature Date : __________________
D. HOSPITAL DIRECTOR SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM Recommended Not Recommended
Remarks:
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__________________________________________________________________________________________
_____________________________
Signature Date : __________________
