UNIVERSITY OF SANTO TOMAS

FACULTY OF MEDICINE AND SURGERY

ETHICS REVIEW BOARD
España Blvd., Manila 1015 Philippines

ERB APPLICATION FORM

Receiving Stamp/
Instruction: Attach this form to the initial submission/resubmission of protocol Date of Submission:
packages/dossier.

For further information, contact:

Ms. Rhea Llemos
The ERB Secretariat
nd
USTFMS ERB Office: 2 Floor St. Martin de Porres Bldg.
Tel No (+632) 7861611 local 8292

Protocol
No./
Title:
Principal Investigator:

Address: Contact Nos.:

E-mail Address:
Co-Investigator: Department/Section:

Office Address: Contact Nos.:

E-mail Address:
Sponsor:
Office Address: Contact Nos.:
Fax Phone:
Contract Research Organization (CRO):
Office Address: Contact Nos.:
Fax Phone:
Research Coordinator: Contact Nos.:
Category of Company Investigator Investigator Consultants UST Non- UST
Study/ Sponsored Initiated/ Initiated/ Faculty Students
Investigator Funded Non-Funded

clinical trial (RCT), placebo- epidemiology basic research social research; herbal
controlled, double-blind research
Types of process research/ diagnostic genetic/genomic health informatics in-vitro study
research operations
review of medical records; survey research on others
indigenous
Use of children under 19 indigenous elderly homeless pregnant
special people persons women
population patients in emergency care poor & refugees or patients w/ incurable others
unemployed displaced persons disease
Clinical No. of Subjects: Study Budget for UST-FMS:
Trial I II III IV PMS
Phase: (attach copy)
Study Site (specify office location): Study Duration:

Review Fee: (specify amount) Institutional Fee: (specify amount)

Bank Name/ Bank Name/

Check No.: Check No.:
Payment Status: Charge Slip No./ Payment Status: Charge Slip No./
Paid: Cancelled: Paid: Cancelled:
Verified by: ERB Secretary Official Receipt No. Verified by: ERB Secretary Official Receipt No.

Required UST: (Attach list) Central Lab: Other Local Labs:

Laboratory/ (specify name of Central Lab) Not acceptable
Ancillary
Procedures
I have no conflict of interest in any form (financial, proprietary, professional) with sponsor, the study, Co-
Investigators, or the site.

Declaration

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of Conflict of I have personal/family financial interest in the results of the study
Interest (COI) Nature:
of Principal
Investigator
(PI) I have proprietary interest in the research (patent, trademark, copyright, licensing)
Nature:

<Title, Name, Surname>

Submitted
by: Study Designation: PI Signature:

To be filled-out by the USTFMS ERB Administrative Secretary:

Date of Initial Review: Date of Approval: ERB Reference No.

Clinical Trial Agreement: Date of Validity: Documents checked by:

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