FORM NO. 1: APPLICATION FORM FOR ETHICAL CLEARANCE
For Official use only
Name, date and signature of the BMC/ CUHAS
E&R Committee Member receiving the
Instructions. All applications for ethics approval should be submitted using this form. The Principal Investigator is required to ensure the information
provided is accurate and will sign on this form to indicate that he/she approves the content. The information provided in this form is
expected to be complete and adequate for reviewers to make a decision on the final disposition of the proposal.
The Application Form must be TYPED. Handwritten forms are not acceptable. Responses should be typed in the blank space/field after each
question. All forms to be handed in must be complete in full and relevant signatures must be provided. Should this not be done, the
evaluation process will not commence. The form shall be handed to the Ethics & Review Secretariat with one copy of the full proposal and
the receipt for the payment of the clearance fee.
Title of Proposal/ Project
Name of the Principal Investigator (PI)
Nationality of the PI
Current qualifications of the PI
Position/ Academic title
Institution/ Department/ Unit
Signature of the PI
If Research student: Name, Signature and approval of
Supervisor (include approval letter
Contact details for correspondence (include the name
of contact if different from the PI)
Collaborating Institution(s) and contact person
All co-investigators (local and foreign)
Not For Degree purposes
:For Degree purposes
:For Masters purposes
:For PhD purposes
Abstractof the proposed Research
Starting and Ending dates
Research site in Tanzania
Research site outside Tanzania (if any)
Budget (Tshs or $)
Source of funds/sponsor
Describe further if necessary
Will this study involve the taking of blood and/or any other biological samples?
Will this study involve shipment of biological samples outside Tanzania?
If Yes, Please attach Material Transfer Agreement from NIMR
Will this study involve data sharing/transfer outside Tanzania?
If Yes, Please attach Data sharing/transfer agreement from NIMR
If this an externally sponsored research?
If Yes, Please attach ethics approval letter from foreign ethics committee
Have you applied for ethics approval from the NIMR National Ethics Committee? Please attach if applicable
District / Medical Officers
Is the technology required for analysis of the samples available in Tanzania?
If YES, please explain why are samples being taken outside the county
Would local scientist(s) be involved in sample analysis?
If YES, describe her/his involvement, and if NOT please explain what are the strategies of technology transfer
Participant information leaflet is attached. (for written and verbal consent)
Informed Consent Form is attached. (For written consent)
Describe how you are going to assess the comprehension of the information provided the consent process
If a Questionnaire or Interview is to be used in the research, it must be attached.
Is it attached? If not, the applicant cannot be considered.
Age range of patients/participants/controls:
If under 18 years, from whom will consent be obtained?
FEES FOR ETHICAL CLEARANCE FROM THE CUHAS/ BUGANDO
Proposal from Tanzanian Institutions and / or on local
Proposal with foreign collaborators
Proposal from Tanzania students (MMED, MPH, MSc)
Proposal for Tanzania students (PhD)
Proposal from foreign students (Masters)
Proposal from foreign students (PhD)
Amendments of a proposal
Application for renewal of ethical clearance
Application for amendment of ethical clearance
(foreigners or collaboration with foreigners)
Application for renewal of ethical clearance (foreigners or
collaboration with foreigners)
PROCEDURE FOR PAYMENT:
Pay to CUHAS account no. 02J1054045500 (USD Account) and 01J1054045501 (Tshs Account) at CRDB Bank.
Bring the deposit slip to the cashier's office.
Get an official receipt.
Present the receipt, together with the application form for ethical clearance and a copy of your proposal to the Research
& Innovations Administration Office (Mr .G. Luena) to proceed with the Ethics & Review process.
Copyright (c) 2003-2021. Developed by Directorate of Information Systems.
Catholic University of Health and Allied Sciences (CUHAS-Bugando)
Application form for ethical clearance - Version 2 - June 2021