Institutional Review Board (IRB)

Dow University of Health Sciences

Baba-e-Urdu Road
Karachi, Pakistan
Tel: 021-32745827
Web: www.duhs.edu.pk
Email: [email protected]

APPLICATION FORM
Checklist

Two copies of Research Protocol with checklist.

Two copies of Drug Brochure or any supplementary information enclosed (if

applicable).

Two copies of informed consent both in English and Urdu or any other local
language of the population study.

Two copies of Questionnaire being administered during the study (if

applicable).

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 Two copies IRB Application form.

Soft copies of all above documents will be sent [email protected] at the time
of submission.

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Signature: Principal Investigator Date

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Signature of supervisor (if applicable) Date

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Signature of Chairman/ Incharge Department Date

Institutional Review Board

Dow University of Health Sciences

How to complete this form and begin the IRB review process

1. This form must be typed and not handwritten.

2. Fill all of the questions on this form completely. For any queries please
contact the Research Office, Dow University of Health Sciences. Email:
[email protected] (Please wait for 7 – 10 days for the response).
3. Students’ research project has to be signed by the supervisor.
4. Fill and attach the appropriate appendices required in this application.

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5. Attach supporting documentation: consent form(s), protocol, survey
instruments, interview schedules, advertisements, letters of permission, etc.
Consent form and questionnaire should also be submitted in local languages
where ever applicable.
6. Complete the accompanied checklists ensure there all requirements for
submission are completed so that review is not delayed.
7. Submit this application and appendices along with the supporting documents
to the Research Department Dow University of Health Sciences, Baba-e-Urdu
Road Karachi Pakistan.

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Principal Investigator Information:

Title: Name:
Designation: Department or Unit:
Mailing address (Office):

Phone: Email:
Signature of PI: Date:

Co Investigators Information:

1.
Title: Name:
Designation: Department or Unit:
Mailing address (Office):

Phone: Email:
Signature of Co Investigator: Date:

2.
Title: Name:
Designation: Department or Unit:
Mailing address:

Phone: Email:
Signature of Co Investigator: Date:

If, there are more than three authors, please write down only the names and
institution for of remaining other authors.

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1. Title of Research/Project: ________________________________________

2. Select one of the category for your research project.

a. Clinical trial on a medicine/drug

b. Clinical trial on a medical device
c. Experimental/ surgical procedure/s
d. Study administering questionnaires/interviews for quantitative or mixed
qualitative/quantitative methods.
e. Study involving qualitative methods only
f. Study limited to working with human tissue samples, other human biological
samples and/or data
g. Research data base (secondary data analysis only)
h. Research involving animal subjects

If any other category then please write down in the space given below

___________________________________________________________

Note: Please provide details if study is related to Experimental drug(s) or Non-

approved use or non-approved dos age for approved drugs

3. Do you plan to include any participants who are children or pregnant women?

Yes  No 

(If yes please justify why it is important to include this study population)

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4. Please provide one page summary of the, research, project, including details of
research methodology (use simple language but give details of how study will take
place).

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5. Aims & Objectives of the proposed research.

5. What is the scientific justification for this research?

6. Please enlist the principal inclusion criteria

7. Please enlist the principal exclusion criteria

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8. Please give in detail methodology and procedures involved in this study.

9. How long do you expect each participant to be in the study?

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10. Please complete the columns for each intervention/procedure as follows:

a.. Total number of interventions/procedures to be received by each participant as

part of the research protocol.

b. If this intervention/procedure would be routinely given to participants as part of

their care outside the research, how many of the total would be routine???

c. Average time taken per intervention/procedure (minutes, hours or days)

d. Who will conduct the intervention/procedure, and where, it would take place.

11. What are the potential risks for research participants and how will you minimise
them? (Describe any potential adverse effects, pain, discomfort, distress, intrusion,
inconvenience or changes to lifestyle. Only describe risks or burdens that could
occur as a result of participation in the research. Say what steps
would be taken to minimize risks and burdens as far as possible)

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12. Will interviews/ questionnaires or group discussions include topics that might be
sensitive, embarrassing or upsetting?

Yes  No 

If yes give details.

13. What are the potential benefits for the research participants?

14. How and by whom will potential participants first be approached?

15. How long will you allow potential participants to decide whether or not to take
part?

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16. What arrangement have been made for persons who might not understand
verbal explanations or written information given in Urdu/English, or who have special
communication needs? (E.g. translation, use of interpreters)

17. Please describe the physical security arrangements for storage of personal data
during the study.

18. How will you ensure the confidentiality of personal data? Please provide a
general statement of the policy and procedures for ensuring confidentiality, e.g.
anonymisation or pseudonymisation of data.

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19. Who will have access to participants' personal data during the study?

20. Ownership of the data.

21. Laboratory and Radiological studies:

a) Will any tests be performed which are not routinely included as part of the
work-up for these types of patients?

b) Who or what agency will pay for these tests?

22. How do you intend to report and disseminate the results of the study?

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23. Will you inform participants of the results of the study?

Yes  No 

Please give details of how you will inform the participants or justify if not doing so.

24. What is the primary outcome measure for the study?

25. What is the sample size for the research? How many participants/samples/data
records do you plan to study in total?

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26. How was the sample size decided upon? If a formal sample size calculation was
used, indicate how this was done, giving sufficient information to justify and
reproduce the calculation.

27. Has funding for the research been secured?

 Funding secured from one or more funders

 Funding application to one or more funders in progress
 No application for external funding will be made
 Give details.

28. Has this or a similar application been previously rejected by a Research Ethics
Committee in Pakistan or another country?

Yes  No 

29. How long do you expect the study to last in Pakistan?

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30. Is this study?

 Single centre

 Multicentre

 Did you acquire many permission for the incharge of centre/s for this study.

31. Where will the research take place?

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