YAYASAN KARYA HUSADA KEDIRI

Keputusan Menkumham RI No. AHU-5902.AH.01.04.Tahun 2011 AS

Y A YE D I R AI N
STIKES KARYA HUSADA KEDIRI K
Ijin Mendiknas RI No. 164/D/O/2005
LEMBAGA PENELITIAN DAN PENGABDIAN MASYARAKAT
(LPPM)

K A

A
R Y
A H U SA

D
Jl. Soekarno Hatta No. 07 Telp. (0354) 399912 Fax 393888 Pare Kediri
Website : www.stikes-khkediri ac.id

KETERANGAN KELAIKAN ETIK

Nomor : ........../EC/LPPM/STIKES/KH/......./2016

Setelah Tim Etik Penelitian mempelajari dengan seksama rancangan penelitian yang diusulkan, :

Judul proposal : ..
..
..
..
Peneliti : ..
Prodi : ...........................................................................................................
Tempat Penelitian : ..

Maka dengan ini menyatakan bahwa penelitian tersebut telah memenuhi syarat laik etik.

Kediri, 2016
Komite Etik Penelitian
Ketua,

Efa Nur Aini, S.Kep.Ns.,M.Kep

NIDN : 07-0403-7601
 FORMULIR ETIK PENELITIAN KESEHATAN

ANIMAL RESEARCH

Nama pembimbing :

1.
2.

Nama peneliti

1.

1. Tujuan :
o Penelitian
o Pelatihan/ training
o Pembiakan
o Lain-lain : ...............................................................................................................
2. Waktu penelitian :
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3. Data hewan coba :
Spesies : .......................................................................................................
Umur : .......................................................................................................
Jenis kelamin : .......................................................................................................
Berat : .......................................................................................................
Jumlah : .......................................................................................................

4. Masalah etik yang mungkin akan dihadapi :

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5. Prosedur penelitian (frekuensi perlakuan, dosis, dan tindakan) :
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6. Bahaya potensial dan cara mengatasi kejadian tersebut (nyeri dan rasa sakit
pada hewan) :
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7. Pengalaman terdahulu (sendiri atau orang lain) dari tindakan yang akan
dilakukan :
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8. Bagaimana cara memilih hewan yang sehat?
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9. Jika menggunakan hewan sakit jelaskan diagnosa dan siapa yang bertanggung
jawab merawatnya. Bila menggunakan hewan sehat jelaskan cara pemeriksaan
kesehatannya!
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10. Jelaskan cara pencatatan selama penelitian, termasuk efek samping dan
komplikasi bila ada!
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11. Bagaimana memperlakukan hewan coba bila ada gejala efek samping?
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12. Bagaimana cara mengamankan hewan agar tidak mengganggu lingkungan
sekitar?
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13. Hewan coba setelah dipergunakan, apakah dimusnahkan? Bagaimana cara
memusnahkan hewan coba?
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RINGKASAN USULAN PENELITIAN

Ringkasan

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Kata kunci :
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Pernyataan dan tanda tangan

Yang bertanda tangan di bawah ini :

Nama : ..........................................................................................................

Jabatan : ..........................................................................................................

Bertindak sebagai : ..........................................................................................................

Judul penelitian : ..........................................................................................................

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Telah membaca dan mengerti tentang isi informasi sekaligus mengisi formulir ini dan

bertanggungjawab terhadap pelaksanaan penelitian tersebut di atas.

Kediri, ...................................... 2016

Peneliti,

NIM :