MTI - HAYATABAD MEDICAL COMPLEX, PESHAWAR

General Ethical Approval Form, Institutional Research Ethics Board (IREB) 

FOR OFFICIAL USE

Manuscript / Approval No. ________/HEC/B&PSC/2025.       Date of Receiving :_____/____/ 2025

FOR APPLICANT USE

Title of Project:  ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ .

Principal Author:  _____________________________________________________

Contact No: _______________________            email: ________________________ 

FOR IREB COMMITTEE MEMBERS / CHAIRMAN

Ethical Committee Observation:

Approved

Not Approved   

Return with Remarks

Date: ¬¬ / /____

CONFIDENTIAL

Important note: - This form should be completed and returned by email to Secretary Institutional Ethics Committee at least eight weeks before the expected dated of execution of the research project. 

Please submit two hard copies as well, No application will be processed without a hard copy.

1. Title of the project:___________________________________________________

___________________________________________________________________

2. Name of Co-investigator(s):_____________________________________________

3. Qualification of Principal investigator / Co-Investigator (s) if any:_______________

4. Name of the Head of the Department: _____________________________________

5. List any potential/approved funding and its sources to carry out the project?

_______________________________________________________________________________

6. Summary of the project including objectives and methods: please do not exceed 500 words/ a single page summary may be attached instead.

7. Will the project involve human subjects?    YES        NO

8. Will animals be used in the research project?  If yes, please give details. YES        NO

9. Will the study involve special situations like involvement of children, pregnant women, physical / mental handicap, prisoners and or any other vulnerable population? If yes, please give details. _______________________________________________________________

10. List the variables that will be included in the project using interview, clinical examination, investigation, procedures or questionnaire etc. ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬___________________

______________________________________________________________________________

11. What are the expected numbers of participant(s)/ subjects / cases? _____________

12. What are proposed start and end dates of the project? ________________________

13. Will the participant (s) be compensated in any form including cash payment? If yes, please give details. _______________________________________________________________

14. Will you obtain the informed consent of the participant?  If yes, what kind of consent will you be taking? In case of written consent, please give details for adults or children using: in case of verbal consent, indicate what you will include in your verbal consent: _____________________

____________________________________________________________________

15. Will the participants have the right to access their own information related to the project for instance results of lab tests etc? if No. give reason / justification.

____________________________________________________________________

16. Is there any information that you would like to keep confidential from the participant?       If yes, please give reasons. ________________________________________________________

17. What steps will you take to keep the data confidential during and after the completion of the project? Also indicate for how long would you keep the data?_______________

____________________________________________________________________

18. Is there any potential harm to the study participants or patients? If yes, what steps would you take to minimize the harm?______________________________________________________

19. Is there any potential benefit to the study participants or patients? If yes, please enlist / describe. _______________________________________________________________________

20. How did you ensure that the potential benefits of your project outweigh the potential harm?  Please describe. ___________________________________________________________

21. Is there any potential harm to yourself or other participating staff members? If yes, what steps have been taken to minimize the harm? __________________________________________

22. Will there be any drugs and /or devices involved in the research? If yes would you explain the potential risks and benefits to the patients?_________________________________________

23. Is there any potential environmental risk involved in the project? If yes, what steps would you take to minimize that?¬¬¬¬¬¬¬¬¬¬__________________________________________________________

24. Is there any conflict of interest at any stage of the project? (i.e. including during the project, dissemination stage, potential gains after completion of the project or any other that you should mention prior to execution of the project) if yes, please give details._________________________

____________________________________________________________________

25. Could the research project or part of the project in any way or at any stage create conflict to the cultural norms or religious belief of the participants involved? If yes, what remedial steps will you take to minimize or eliminate such conflicts? _________________________

____________________________________________________________________

26. Is the research likely to have any negative impact on the reputation of the institution? If yes, what steps would you take to minimize / eliminate such potential risks? _________________

____________________________________________________________________

Important note:   Please note that any change in the project for any reason, leading to any modification in the project objectives/methods etc. shall be notified to eh IEC prior to project execution on revised plan. In such cases resubmission for fresh ethical approval of the project will be required.

The IEC shall be informed in writing if the project is discontinued for any reason, along with the reasons of discontinuation.

In cases of joint venture with other organizations/institutions, ethical approval of the IEC of 

MTI-Hayatabad Medical Complex, Peshawar will still be required, even if the IEC of the other organization / institution has already granted ethical approval. Please attach a copy of the ethical approval of the other organization.  

Signature of Applicant                                                                   Date: _________________.

Email address:  PROF. DR. LIAQAT ALI

                       liaqat_99@yahoo.com                        

ATTACHMENTS:

1. Supervisor Certificate 

2. Non Duplication certificate

3. Declaration

4. Questionnaire

5. Patient Consent Form English and Urdu both 

NOTE: Incomplete applications will not be considered.