Write down your email please.

Is this a standard procedure in Universiti Malaya Medical Centre (UMMC)?

Will there be any new and unregistered drug used in this research?

Is there any new procedure and/or test conducted in relation to this research?

Are you expecting any Adverse Event (AE) in this research?

Please specify the number of subject(s) to be recruited into this research.

Please state the name of person conducting the research.

Is the name stated in point no. 6 an UMMC staff?
YESNO

Does the person in point no. 6 hold an active C&P certificate?
YESNO

Is the person in point no. 6 APC certified?
YESNO[cf7mls_step cf7mls_step-1 "Next" ""]PDF copy of MREC application that includes MREC review/comments

Research Protocol received

Patient Information Sheet

Informed Consent Form

Is your research has any relation to ionising radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel?
YESNO

Is your research related to any radioactive toxic explosive or other hazardous properties of any explosive nuclear assembly or nuclear component?
YESNO

Is your research arise from Hepatitis or any condition directly or indirectly caused by or associated with Human T-Cell Lymphotropic Virus Type iii (HTLV iii) or Lymphadenopathy Associated Virus (LAV) or the mutants derivatives or variations thereof?
YESNO

Is your research related to Acquired Immune Deficiency Syndrome or any syndrome/condition of a similar kind howsoever it may be named?
YESNO

Is your research associated with Transmissible Spongiform Encephalopathy (TSE) Creutzfeldt-Jakob Disease (CJD) variant Creautzfeldt-Jakob Disease (vCJD) or new variant Creutzfeldt-Jakob Disease (nvCJD)?
YESNO

Will your research expose UMMC to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America?
YESNO

Is your research involving recruitment of any pregnant research subjects?
YESNO

Does your research involve the research, investigation, treatment and/or study into the fertility or pregnancy of a research subject?
YESNO

Does your research involve the research, investigation, treatment and/or study of a fetus in utero?
YESNO

Does your research involve the recruitment of research subject under the age of five (5) years at the time of research?
YESNO

Does your research involve any Covid-19 clinical trial of an investigational medicinal product?
YESNO[cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"]I hereby understand my responsibility as an investigator and will duly comply with the protocol and applicable rules, regulations and guidelines governing the research.

I hereby understand that my research must be approved by the UMMC MREC and all required authorizations, and this insurance will be void in the event if such ethics committee or authorizations reject, cancel and/or terminate my research.

I hereby understand that this insurance does not provide coverage for the failure of a pharmaceutical or medical device under research to perform its intended purpose.

I hereby understand that the amount of compensation may be reduced, denied or affected if the seriousness of the injury treated in research and the degree of probability that AE would occur with the consideration that warning has been given to research subject.

I hereby understand that this insurance does not cover any liability caused by or resulting from access to, damage to or loss, destruction, erasure, corruption or alteration of electronic data.

I hereby understand that this insurance does not cover any liability caused by or resulting from errors in creating, amending, entering, deleting or using electronic data.

I hereby understand that this insurance does not cover any liability caused by or resulting from inability, delay or failure to receive, send, access, permit access or use of electronic data.

I hereby understand that this insurance does not cover any liability caused by or resulting from access to or disclosure of any personal or corporate information.

I hereby understand that this insurance does not cover any liability caused by or resulting from hacking, cyber attack, virus, worm, spyware, trojan horse, phishing or malicious computer programme.

I Agree to the terms and conditions stated above.

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