Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino de las Alas Campus
Indang, Cavite
( (046) 862-0939 / 862-0940 www.cvsu.edu.ph CvSU ERB FORM 01. PROTOCOL PACKAGE RECEIPT

STUDY CODE:
TITLE:
PROPONENT:

To the principal investigator/research proponent: Kindly arrange the required (with bullets) and other documents in your protocol package according to the following order. Write NA if the document is not applicable.
| | | |
|Original plus 7 copies of the ff: |NA |DATE Received at ERB with Proponent/Investigator/Representative|
| | |and ERB secretariat initials |
|Endorsement Letter from the research grant if applicable | | |
|Accomplished ERB Form 02 -Request for Review of Protocol | | |
|Accomplished ERB Form 03- Permit to Conduct the Study and | | |
|Informed Consent (English and Filipino) | | |
|Accomplished ERB Form 04 – Ethics Review Board Ethical Review | | |
|Checklist | | |
|CV of PI and Co-investigators/Proponents | | |
|GCP and/or Research Ethics Training Certificate/s | | |
|List of study team members with brief job descriptions | | |
|Protocol | | |
|Questionnaire | | |
|Interview guide | | |
|Informed Consent in English | | |
|Informed Consent in Filipino | | |
|Assent for minors/vulnerable group | | |
|Investigator’s brochure | | |
|CDs of Synopsis of Protocol containing Title, PI, Department, | | |
|Sponsor, Primary Objective/s, Brief Methodology, No. of | | |
|participants to be recruited; Study site/s, Duration of study, | | |
|Inclusion and Exclusion criteria, Study Diagram and Flowchart, | | |
|and Statistical Analysis and Plan | | |
|Agreements/contracts (specify) | | |

Other documents being submitted (specify):
|Document Description |Version Number |Version Date |
| | | |
Please coordinate with the ERB Secretariat should you need clarification regarding your protocol package’s review track.

Date Submitted: ________Submitted by: _______________________Contact No.__________________ Name and Signature

Package Received by: ____________________________________ Date: _______________________ ERB Secretariat (Name and Signature)

___________________________________________________________________________________

FOR ERB :

REVIEW PACKAGE RECEIVED BY:

_______________________________________________________Date________________________ ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date:_______________________ ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date________________________ ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date________________________ ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date________________________ ERB Reviewer/Representative’s Name and Signature