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AF/01-13/01.0 Suranaree University of Technology

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AF/01-13/01.0 Suranaree

University of Technology Institutional Ethics

Committee

Study Report Form (Final Report)

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Please attach the Executive Summary or Abstract of the study with this report

Protocol No.: COA. No.

Protocol title:

Study Code:

Principle Investigator:

Phone E-mail:

Sponsor’s Name Address:

Phone E-mail:

Study site (s):

Total Number of study

participants: No. of Study Arms:

Number of participants recruited in the study:

Study materials:

Treatment form:

Study dose(s):

Duration of the study Objective:

Investigator signature ………...……….……….

……… Date ……… /……… /………

(Please retain copy of the completed form for your study record)

Reviewer Comments (โโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโ โโโโโโโโโ โโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโ)

(2)

( ) Date:

……….…………

Reviewer’s signature

Referensi

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