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ERC-Form-1

The document is an application form for the Ethics Review Committee regarding a research study on Pine Needle Essential Oil as a mosquito repellent. It includes basic information about the study, such as the authors, submission date, and required documents. The form also outlines the type of review requested and provides space for evaluation by the committee chairperson.

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Edwin Nabal-ojr
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6 views2 pages

ERC-Form-1

The document is an application form for the Ethics Review Committee regarding a research study on Pine Needle Essential Oil as a mosquito repellent. It includes basic information about the study, such as the authors, submission date, and required documents. The form also outlines the type of review requested and provides space for evaluation by the committee chairperson.

Uploaded by

Edwin Nabal-ojr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PCC – ERC Form 1

ETHICS REVIEW COMMITTEE


RESEARCH PROTOCOL ETHICS REVIEW
APPLICATION FORM

Study Protocol Title:


Pine Needle (Pinus kesiya) Essential Oil as a Mosquito Repellent Formulated as Patch
Author/s or Principal Investigator/s: Protocol File No.
Lauriano, Edward Allen F.
Atos, Georgette Q.
Intugay, Krizza Mae A.
Ringor, Jenica F.
Racela, Ria Amber D.
Submission Date: January 13, 2025 Institution: Pines City Colleges
Submission by: (Name & Signature) College/Department:

EDWARD ALLEN F. LAURIANO College of Pharmacy

BASIC INFORMATION ABOUT THE STUDY:


Key Features Yes/No Remarks
Involves experimental procedures
Involves non-experimental procedure like
survey, interviews, and the like
Involves human subjects; No. of human
subjects
No. of study sites
Main study site, address
Other study sites
Duration of implementation of study
Proposed date of start of study

DOCUMENTS SUBMITTED:
Documents Yes/No; n/a Remarks
Research Protocol
Attachments
Informed Consent
Data Collection Forms/Instruments
Curriculum Vitae of Researcher/s
Study Gantt Chart
Others

Received by: Type of Review: _____ Exempted


_____ Expedited
_____________________________ _____ Full- Board
Secretary, PCC-ERC
Date: ______________

/ERC-FORM 1/2019 VERSION/VPAA FILE/ 1


Evaluated by:

___________________________________
Chairperson, PCC-IRC
Date: _________________________

/ERC-FORM 1/2019 VERSION/VPAA FILE/ 2

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