University Ethics Review Committee

Center for Research and Development

900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

FINAL REPORT

INSTRUCTIONS TO THE PRINCIPAL INVESTIGATOR: This form is required upon completion of the study or
closure of study site. This must be submitted within thirty (30) days after the study has been completed.

I. PROTOCOL BASIC INFORMATION

Title:

Approval Date: Last Reviewed Study Site: Duration of the Study:

__/__/____ __/__/____ From _ _/_ _/ _ _ _ _ To _ _/ _ _/ _ _ _ _
Principal Investigator (PI):
Email: Mobile Number:
Sponsor: Contact Person:
Email: Mobile No.:

II. PROTOCOL
1. Objectives of the Study and Summary of Results

Objectives of the Study Summary of Results

2. Number of participants: Beginning of the study: _____________ End of the Study: _______________
Number of participants who received the TEST ARTICLES. Total Number: _______________________

3. Summary of amendments to the original protocol (including dates of approval). If there is none check N/A.

N/A Brief Description Date of Approval

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5

F-CRD-UERC Form No. 017 Final Report Form

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 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

3. Summary of SAE Reported. If there is none check N/A.

N/A Brief Description

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4. Summary of anticipated risks (other than SAEs) documented in the conduct of study. If there is none check N/A.

N/A Brief Description

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5. Summary of SUSAR report. If there is none check N/A.

N/A Brief Description

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6. Summary of unanticipated risks (others than SUSAR) documented in the conduct of study: If there is none check
N/A.

N/A Brief Description

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F-CRD-UERC Form No. 017 Final Report Form

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 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

7. Summary of participants’ complaints or grievances documented regarding the conduct of the study: If there is none
check N/A.

N/A Brief Description

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8. Summary of benefits documented: If there is none check N/A.

N/A Brief Description

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9. Summary of indemnifications. If there is none check N/A

N/A Brief Description

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10. Continuing Review Application Submission (Progress Report) dates with corresponding Committee action:

Date of UERC Action

Submission
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5

F-CRD-UERC Form No. 017 Final Report Form

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 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

11. Summary of study materials used (for non-clinical research):

12. List of treatments or interventions: If there is none check N/A

N/A Brief Description

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13. List of informed consent form used (version/date) and attach most recent version:
Brief Description (Please attach informed consent Ver. Date
1
2
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14. If terminated, please specify the reason:

III. PREPARED AND SUBMITTED BY:

_________<Signature over printed name>_______________

< Date: MM/DD/YYYY>

F-CRD-UERC Form No. 017 Final Report Form

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 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

IV. OBSERVATIONS AND RECOMMENDATIONS (TO BE FILLED OUT BY UERC REVIEWER ONLY)
☐The protocol adheres to what have been approved by the UERC
☐The protocol falls short of what have been approved by the UERC
☐The protocol deviates/ violates what have been approved by the UERC

Recommendations:

_________<Signature over printed name>_______________

< Date: MM/DD/YYYY>

F-CRD-UERC Form No. 017 Final Report Form

Page 5 of 5
 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

F-CRD-UERC Form No. 017 Final Report Form

Page 6 of 5
 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

F-CRD-UERC Form No. 017 Final Report Form

Page 7 of 5
 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

F-CRD-UERC Form No. 017 Final Report Form

Page 8 of 5
 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

F-CRD-UERC Form No. 017 Final Report Form

Page 9 of 5
 University Ethics Review Committee
Center for Research and Development
900 San Marcelino Street, Manila
1000 Manila, Philippines
Office: (+632)- 524-2011 loc 153
uerc-secretariat@adamson.edu.ph

F-CRD-UERC Form No. 017 Final Report Form

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