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Ethical Review Application

Please fill out all sections of this form accurately. The form is divided into stages. Checklists at the end will require document uploads.

UNIVERSITY OF LIVINGSTONIA (UNILIA)

UNILIA RESEARCH ETHICS COMMITTEE (UNILIAREC)

Application for Ethical / Scientific Review

[REF: SOPs VERSION 01 -2020]

General Information

Date Project Title

Name of all person(s) submitting research proposal

Name Position (e.g. PI, Co-PI) Organization/Institute

Contact & Timeline

Email address Telephone number(s) Postal Address(es)

Study Duration

Begin Date End Date

Study Site

Research Category

Select the category to tailor the checklist requirements.

Healthy Research Clinic Research Humanity Research

Type of Review i.e. BSc, MSc, PhD, Expedited e.t.c

1 Describe the purposes of the research proposed:

2 Summary of design and methodology:

Include details of proposed sample size, indications of calculations used, and any assumptions.

3Research procedures:

As they affect the research subject(s) and any other parties involved.

4Ethical considerations:

Consent, confidentiality, risk to subject(s) etc.

5Justification of possible benefits vs risks:

6Who are the investigators supporting the research?

Qualifications and experience of all involved.

7Clinical facilities for emergencies:

8Access to information from third parties:

9Subjects in dependent relationships:

10Children or vulnerable people:

11Payments or incentives:

12How consent is to be obtained:

13Cultural or gender-based characteristics:

14Measures for data confidentiality:

Payment Details

As per Section 3.9 of guidelines. Payment US $ 150 equivalent to:

Bank Name: National Bank of Malawi

Account Name: University of Livingstonia Research

Account Number: 1004679128

Upload Proof of Payment

SIGNATURE : (NAME PRINT) DATE:

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