Nomor FRM-LPM-002

SEKOLAH TINGGI ILMU

KESEHATAN MUHAMMADIYAH Revisike 00
GOMBONG TanggalBerlak 1 Maret 2017
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SURAT PERMOHONAN ETICAL CLEARENCE

KepadaYth:
KetuaTim Etik
Stikes Muhammadiyah Gombong

DenganHormat,
Sehubungandenganakandilaksanakannyapenelitiandengan ini saya
mengajukanpermohonanuntukmendapatkanEthical ClearancedariTim Etik Stikes
muhammadiyah Gombong atasnama :

Nama = ........................................................................
NIM = ........................................................................
Program Studi = ........................................................................
Judul Penelitian = ........................................................................
Rancangan Penelitian = ........................................................................
Tempat Penelitian = ........................................................................
Subyek Penelitian = ........................................................................
Waktu penelitian = ........................................................................
Pembimbing Skripsi = 1 .....................................................................
2 ......................................................................

Bersamaini kami lampirkan3 proposal penelitian

Demikiansuratpermohonanini kami ajukan, atasperhatiandanbantuannya kami
ucapkanterimakasih.

Gombong, ....................
Hormat saya

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