UNDERTAKING FOR ETHICS COMMITTEE NOT ATTACHED TO HOSPITAL

(1) We (1) ________________________________________________________ S/o, D/o, W/o,

_______________________________________________________ Age: _________ and
(2) ___________________________________________________________ S/o, D/o, W/o,
_______________________________________________________ Age: _______ declare
that, we are working as Chairperson and Member Secretary respectively of the Ethics
Committee for Biomedical and Health Research involving Human Participants, namely,
_________________________________________________________________________
____________________________________________ (name of Ethics Committee), having
registered office at ____________________________________________________
_________________________________________________________ (complete address).
Our contact details are as follows -
a. Landline No.: ____________, Mob. No.: _______________, Email ID: ______________
b. Landline No.: ____________, Mob. No.: _______________, Email ID: ______________
(2) We undertake that we are representing M/S ___________________________________
(Firm/Hospital/Institute) and this undertaking is given for registration of the Ethics Committee.
(3) We have read the terms, conditions and privacy policy of the portal of the Department of Health
Research (DHR), i.e., https://naitik.gov.in and agree to them.
(4) We authorize Shri/Smt ___________________________________________ S/o, D/o, W/o
________________________________________________________ Age _______ working
as Member Secretary of the Ethics Committee to register on the DHR portal
https://naitik.gov.in.
(5) We undertake that the applicants will be held responsible for all the acts and deeds performed
on https://naitik.gov.in subsequent to the registration of the Ethics Committee.
(6) We undertake that the login password will be kept confidential and that we will be held
responsible for sharing the same with unauthorized persons.
(7) The information submitted above is true and correct to the best of my knowledge and no part
of it is false and nothing is misleading or has been concealed.
(8) We declare that no other person has been authorized by us, to register on the portal for this
purpose.
(9) I declare that all the submissions and communications made are on the behalf of the Chairman
of the Ethics Committee who has given me the authority in writing to do so.

Signature Signature

Name (In capital letters) Name (In capital letters)

Designation Designation
(Member Secretary of Ethics Committee) (Chairperson of Ethics Committee)

Seal Seal

Signed on ______________
Place: _________________
 UNDERTAKING FOR ETHICS COMMITTEE ATTACHED TO HOSPITAL

(1) I declare that I, _________________________________________________ S/o, D/o, W/o,

_______________________________________________________ Age ___________ am
working as _____________________________ Managing Director/Director/Chief Executive
Officer/Chief Operating Officer/Secretary/ Head of the Institute - in case of Government/ Semi
- Government/Govt. Autonomous Body, (strike off whichever is not applicable) of M/s
______________________________________________ having our Hospital/Institute at
_______________________________________________________________________
_______________________________________________________ (complete address). My
contact details are as follows –
Landline No. _____________, Mob. No. ______________, E-mail Id: __________________.
(2) I undertake that I am representing M/s ___________________________________________
(Firm/Hospital/Institute) and this undertaking is given for registration of the Ethics Committee.
(3) I am the competent authority/ authorized by the competent authority of the
Firm/Hospital/Institute/Organization to delegate this power of attorney.
(4) I have read the terms, conditions and privacy of the Department of Health and Research (DHR)
portal i.e., https://naitik.gov.in and agree to them.
(5) I authorize Shri/Smt ______________________________________________ S/o, D/o, W/o
___________________________________________________, Age ___________ holding
the position of Member Secretary of the Ethics Committee for Biomedical and Health Research
involving Human Participants, namely,___________________________________
_________________________________________________________________________
in our Firm/Hospital/Institute/Organization to register on the DHR portal https://naitik.gov.in.
(6) I undertake that the applicant will be held responsible for all the acts and deeds performed on
the DHR portal https://naitik.gov.in subsequent to the registration of the Ethics Committee.
(7) I undertake that the login password will be kept confidential and that I will be held responsible
for sharing the same with unauthorized persons.
(8) The information submitted above is true and correct to the best of my knowledge and no part
of it is false and nothing has been concealed.
(9) I declare that no other person has been authorized by me, to register on the portal for this
purpose.
(10) I declare that all the submissions and communications made are on the behalf of the Chairman
of the Ethics Committee, who has given me the authority in writing to do so.

Signature:

Name (In capital letters):

Designation:

Seal:

Signed on ______________
Place: _________________