Approval Cover Page
PAGE SOP 4.2-013.2013-03
Medical and Health Research Ethics Committee (MHREC)
Faculty of Medicine Universitas Gadjah Mada
Dr. Sardjito General Hospital
Effective date:
31December 2013
Page 1 of 1
4.2. Review of Protocol Amendments
ANNEX 1
AF 4.2.01-013.2013-03Protocol Amendment Submission Form
PROTOCOL NUMBER:aPPROVED DATE:
PROTOCOL TITLE: Hubungan Pengetahuan Keselamatan dan Kesehatan
Kerja Dan Sikap Penggunaan Alat Pelindung Diri Dengan Kecelakaan
Kerja Pada Pengrajin Pisau Batik Krengseng Di Desa Bangunjiwo
Kabupaten Bantul
PRINCIPAL INVESTIGATOR: : EDWINA RUDYARTI
Institute: Ilmu kesehatan kerjaTelephone: 085727368233
SUBMITTED DATE of AMENDMENT: AMENDMENT NO.
REQUEST FOR AMENDMENT MEMORANDUM (use additional page if
necessary):
State/describe the amendment
Provide the reason for the amendment
State any untoward effects with original protocol
State expected untoward effects because of the amendment
Note: Changes made to the protocol and protocol-related
documents should be clearly marked either with the underlining or
highlighting feature of the software package used to prepare the
document.
SIGNATURES:
Date:.. Principal Investigator
TYPE OF REVIEW:ASSIGNED REVIEWERS:
Exempted from review
Expedited Review
Full Board Review1.
2.
3.
Reviewer for informed consent documents:
COMPLETION:
Date:
Secretary of MHREC-FM UGM
