Form 3.

1 (A) 2010
Research Project Proposal Form

NATIONAL INSTITUTES OF HEALTH

UNIVERSITY OF THE PHILIPPINES MANILA

RESEARCH PROJECT PROPOSAL FORM

ATTENTION:
1. The original form (with original signatures) should be submitted to the National Institutes of Health
Ethics Review Committee with 15 additional copies.
2. All items must be filled-out (printed or typed) properly, otherwise it will not be accepted.

PART I. ADMINISTRATIVE INFORMATION

A. Research
Project Title
(The distinctive name
given to the project
describing the work
scope in specific, clear
and concise terms)

B. Principal Name of Principal Proponent/ Designation / Title Institution

Investigator and Co-investigators Affiliation
Co-investigators (if applicable)
(Name of principal
proponent and co-
investigators,
designation/ title and
affiliate institution)

C. Proponent
I confirm that I have read this application and that, if support is granted, the work will be
Institute / College accommodated and administered in the Department/Institution in accordance with the
(Declaration of
general conditions. I also confirm that the Principal Investigator has a full-time appointment in
institutional
endorsement) this institution.

Institute/College /Unit Institute Director/Dean /Director

(Signature over printed Name)
D. Authorization and
This is to certify that the research site has no local Institutional Review Board/ Independent
Acknowledgment
Ethics Committee (IRB/IEC) and that the research site authorizes and acknowledges the
of Review University of the Philippines-Manila National Institutes of Health – Institutional Review
(Administrative
certification from the Board (UPM NIH-IRB), located in the National Capital Region (NCR) with address at the
study site when the PI Ground Floor, NIH Building, 623 P.Gil St. Ermita, Manila, to perform the ethical review of the
is not from UP Manila study entitled, “TITLE OF PROTOCOL”, in accordance with international ethical standards
and the study site is and national regulatory requirements, and oversee the conduct of the research study which
outside UP Manila) includes progress monitoring, adverse even monitoring, and site visits.

On-site Administrative Authority

(Signature over printed name, indicate position)
E. Research Project
Duration
(The length of time in
1
 which the specific
project activities shall
be accomplished)

F. Cooperating
Agencies/
Research Links
(The agency/ies which
is/are expected to
cooperate/contribute to
the research work.
Collaboration with
other scientist/s and
research institutions or
links with other
research projects)

G. Research (Please put appropriate letter)

Classifications
1. Type of (Note: If applying for ethical clearance ONLY, that is, without an
Scientific and application for NIH Grant, you may skip this section and move on
Technological to G.2)
Activities a. RED – Research and Experimental Development
b. STS - Scientific and Technological Services
c. STET – Scientific and Technical Education and
Training
2. Category of a. Basic Research (Acquiring new knowledge through
Research or experimental and theoretical work)
Project b. Applied Research (Acquiring new knowledge with a specific
application in mind, determining possible uses for basic research
findings or determining new ways of achieving objectives)
c. Experimental Development Research (Using existing
knowledge to produce new materials, products, or devices; installing
new processes, systems, and services; or improving current
production of installation substantially)

3. Purpose of a. Thesis
Research b. Ph.D. Dissertation
c. Postdoctoral work
d. Independent work
e. Others, please specify ____________________

4. Area of a. Clinical
Interest b. Social Science
c. Public Health
d. Molecular Biology and Biotechnology
e. Others, please specify ____________________

H. Summary of the Please write a summary of the research project in the space provided below based on the
Research Project components itemized on the left, and indicate where such components may be found in the
full protocol. Attach the full protocol to this form.

2
 1. Objectives
2. Study
Population
3. Inclusion/
Exclusion
Criteria
4. Study
Design
5. Sample Size
6. Diagram of
procedures
7. Data
Collection Tools
8. Data
Analysis
I. Ethical (Please provide the following information)
Considerations
(Required if the proposal 1. Subject Profile:
involves research on a. Who are the human subjects?
human subjects,
b. How will they be recruited?
including collection of
human blood or other c. What information will be given to them?
human tissue samples. If d. What intervention will they be subjected to?
data is to be stored in
electronic databases, 2. Include a consent form containing all prerequisites of informed consent written in
ensure that all steps to the language of the subject using the informed consent checklist provided.
protect confidential data
are properly followed;
eg: Anonymization of
patient data, removal of
personal identifiers,
security of databases
ensured, etc.)

J. Declaration of Enumerate individual and institutional conflicts of interest such as funding in various forms
Conflict of and institutional affiliations relevant to this application
Interest (Formal
disclosure from
investigator of
information regarding
funding, sponsors,
institutional affiliations,
etc)

3
PART II. RESEARCH PROJECT WORKPLAN SCHEDULE (Project year __________)

ACTIVITIES FIRST SECOND THIRD FOURTH

QUARTER QUARTER QUARTER QUARTER

PART III. RESEARCH PROJECT WORKPLAN OUTPUT (Project year _________)

FIRST QUARTER SECOND QUARTER

THIRD QUARTER FOURTH QUARTER

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PART IV. BUDGET BREAKDOWN (NOTE: This section should be filled out if applying for funding under the
NIH Research Grant. Please indicate other source/s of funding, if applicable)

(For projects of 1-year duration or less AND 1st/ ________ year of multi-year duration)
Program/Project 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL
Personal Services
Salaries
Honoraria
MOOE
Travel Expenses
Supplies and
Materials
Sundry
Laboratory
Exams
Equipment Outlay
TOTAL

Other sources
TOTAL
GRAND TOTAL
(For projects of more than 1-year duration)
Program/Project 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL
Personal Services
Salaries
Honoraria
MOOE
Travel Expenses
Supplies and
Materials
Sundry
Laboratory
Exams
Equipment Outlay
TOTAL

Other sources
TOTAL
GRAND TOTAL

DETAILED FINANCIAL REQUIREMENTS:

ITEM BASIS QUANTITY UNIT RATE/UNIT AMOUNT

PRICE
Personal PI
Services
Co-I
RAs
Sub-total
MOOE 1st release
2nd release
3rd release
Sub-total
TOTAL

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PART V. APPENDICES (If applicable please include the following)

1. Informed Consent Form

2. Patient / Case Report Forms
3. Flow Chart of Activities
4. Questionnaires

PART VI. BIBLIOGRAPHY (this section may be expanded as needed)

1.
2.
3.
4.

PART VII. CURRICULUM VITAE OF PRINCIPAL INVESTIGATOR AND CO-INVESTIGATORS

(1 page maximum for each)

1. Name
College/Institute
Contact Numbers
Email Address
2. Degree(s)
Subjects, university or school, year
3. Training
Certifications of successful completion of protocol-related training, research ethics training, and Good
Clinical Practice (GCP) training, as applicable
4. Present Posts / Positions held
Type of post, institution/faculty/ department, dates
5. Recent Publications
List only the five (5) most important publications or papers most relevant to this proposal over the last 5
years (papers in press or submitted or publication are also acceptable). Please give full bibliographic
references (author/s, title, journal, volume, page numbers, years). If applicable, please attach copies of
papers in press or submitted if these contain background material relevant to this proposal.
6. Concurrent Projects
Enumerate all on-going projects and projects that will commence within the next three months. Indicate
project involvement (PI, Co-I, Sub-I, Consultant, etc.), start dates, and expected completion dates.

Signature: Date: