From 30.9.

18
A.Arunkumar,S.Gopinath,M.Raja,A.Sanjay,V.Santhosh Kumar.
III MBBS students,
Government Medical College,
Omandurar Government Estate,
Chennai - 02.

To
The Chairperson,
Institutional Ethics Committee (IEC),
Government Medical College,
Omandurar Government Estate,
Chennai - 02.
Through Proper Channel
Respected Sir/ Madam,
Sub: Submission of research study proposal for IEC approval - Regarding.
Ref: Circular from IEC, GMC, OGE, Chennai -02. Dated: 22.09.18

We have proposed to conduct a research study titled “A study on Knowledge, Attitude

and Practices on Organ Donation among College Students”. Herewith we are submitting the
research study proposal to be conducted in the Colleges in Chennai under the Dept, of
Community Medicine, GMC, OGE, Chennai-02. between October and November 2018, under
the guidance of Dr.M.Uppili Venkat Ragavan, Assistant Professor, Dept. of Community
Medicine, GMC, OGE, Chennai. We assure that this study will be conducted according to the
regulations of the Institutional Ethics Committee. We request You to kindly review the proposal
for IEC approval to conduct the research study.

Thanking you

Yours Sincerely,
Forwarded by:
Dr.M.Uppili Venkat Ragavan, 1.A.Arunkumar,
Assistant Professor, 2.S.Gopinath,
Dept. of Community Medicine, 3.M.Raja,
GMC, OGE, Chennai-02. 4.A.Sanjay,
30.09.2018 5.V.Santhosh Kumar
Chennai-02.

Enclosures: 10 printed copies of the research study protocol

From 30.09.2018
Dr.M.Uppili Venkat Ragavan,
Assistant Professor, Department of Community Medicine,
Government Medical College, Omandurar Government Estate,
Chennai - 02.

To
The Chairperson,
Institutional Ethics Committee (IEC),
Government Medical College, Omandurar Government Estate,
Chennai - 02.

Through Proper Channel

Respected Sir/Madam,

Sub: Submission of research study proposal for IEC approval - Regarding.

Ref: Circular from IEC, GMC, OGE, Chennai -02. Dated: 22.09.18

Herewith I am forwarding the research study proposal titled “A study on Knowledge,

Attitude and Practices on Organ Donation among College Students”. to be conducted in the
Urban field practice area under the Dept, of Community Medicine, GMC, OGE, Chennai-02.
between October and November 2018 by the III MBBS students -
A.Arunkumar,S.Gopinath,M.Raja,A.Sanjay,V.Santhosh Kumar under my guidance. I assure that
this study will be conducted according to the regulations of the Institutional Ethics Committee. I
request you to kindly review the proposal for IEC approval to conduct the research study.

Thanking You,
Yours Sincerely,

Forwarded by: (Dr.M.Uppili Venkat Ragavan)

Dr. R. Kannan, MD,
HOD (I/C), Department of Community Medicine,
Government Medical College, Omandurar Government Estate,
Chennai - 02.

30.09.2018
Chennai-02.
Title of the Proposal:
Name of the Investigator:
Name of the Co-investigator:
Name of the Guide:
Name of the HOD:
A study on Knowledge, Attitude and Practices on Organ
Donation among College Students
1. A.Arunkumar,
2. S.Gopinath,
3. M.Raja,
4. A.Sanjay,
5. V.Santhosh Kumar.
_
Dr.M.Uppili Venkat Ragavan,M.D.,
Assistant professor, Department of Community Medicine,
Government Medical College,
Omandurar Govt. Estate, Chennai-02.
Dr.R.Kannan, MD,
HOD (I/C),
Department of Community Medicine,
Government Medical College,
Omandurar Govt.Estate, Chennai-02.
 INFORMED CONSENT FORM

Study title: A study on Knowledge, Attitude and Practices on Organ Donation among
College Students

Participant name: ______________________________ Age: _______________ Sex: _______________

1. I confirm that I understood the details of the above study from the patient information sheet
and the consent form that I read / the investigator has read and explained.
2. I have had the opportunity to clarify all my queries and doubts and they have been
answered to my satisfaction.
3. The Investigator had explained very well about the study and I am made aware of the
advantages and less than minimal risks involved in the study.
4. I understand that my participation in the study is purely voluntary and does not include any
monetary benefit.
5. I have understood that I am free to withdraw from the study at any time during the study
period without giving any reason.
6. I have understood that the investigator, regulatory authorities and the ethics committee will
have access to my data both in respect to current study and any further research that may be
conducted in relation to it, even if I decide to withdraw from the study.
7. I have understood that my identity will not be revealed in anyway and my personal
information released to third parties or published, unless as required under the law.
8. I agree not to restrict the use of any data or results that arise from the study.

I hereby consent to participate in this research study whole heartedly without any compulsion
and with a clear state of mind.

Signature of the investigator: Signature / thumb impression of Participant:

Name of the investigator: Participant’s name:

Date:
Place:
 ஆஆஆஆஆஆஆ ஆஆஆஆஆஆஆஆஆஆஆஆஆஆ ஆஆஆஆஆஆஆஆ ஆஆஆஆஆஆ

ஆஆஆஆஆஆஆ ஆஆஆஆஆஆஆ:

ஆஆஆஆஆஆஆஆஆஆஆஆஆஆ ஆஆஆஆஆ: ______________________________ ஆஆஆஆ: _______________ ஆஆஆஆ: _______________

1. நநநந, நநநநநநந நநநநந நநநநநநநநநந நநநநநந நநநநநநநநநநநந நநநநநநநந நநநநநநநநநநநந

நநநநநநந / நநநநநநநந நநநநநநநநநநந நநநநநநநந நநநநநநநந.
2. நநநநநநந நநநநநநநநநநந நநநநநநநநநந நநநநந நநநநநந நநநநநநநநநநநநநநநநநநநந. நநநந
நநநநநநநநநநநநந நநநநநநநந நநநநநநநநந நநநநநநந நநநநநநநந நநநநநநநநநநநந.
3. நநநந நநநநந நநநநநநநநநநநநந நநநநநந நநநநநநநந நநநநநநநந, நநநநநந நநநந நநநநநநந
நநநநநநநநநநநந நநநந நநநநநநநநநநநந நநநந நநநநநநநந நநநநநநநந.
4. நநந நநநநநநநந நநநநநநந நநநநநநநநநநந நநநநநநநந நநநநநந நநநநநநநநந நநநநநநந நநநந
நநநநநநநந நநநநநநநந.
5. நநநந நநநநநநந நநநநநநந நநநநநநந நநநநநநநநநநநநநநநந நநந நநநநந நநநநநநநநநநநநந நநநந
நநநநநநநநநநநநநநநந நநநநநநந, நநநநநந நநநநநநநநநந நநநநநந நநநந நநநநநநநநநந நநநநநநநந
நநநநநநநநநந நநநநநநந.
6. நநநந நநநநநநந நநநநநநந நநநநநநநநநந நநநந நநநநந நநநநநநந நநநநநநநந நநநநநநநந நநநநநநந
நநநநந நநநநநநநந நநநநநநநநந நநநநநநநநநநநநநநநந நநந நநநநநநந நநநநநநநநநந நநநந
நநநநநநந நநநநநநந நநநநநந நநநநநநநநநந நநநநநநந.
7. நநநந நநநநநநந நநநநந நநநநநநநநநநநந நநநந நநநநந நநநநநநந நநந நநநந நநநநநநந நநநநநநநந
நநநநநநநந நநநநநநநநநநநந நநநநநந நநநநநநந.
8. நநநந நநநநநநந நநநநநநநநந நநநநநநநநநந நநநநநநநந நநநநநநநந நநநநநநநந நநநநநநநநநநநநநநந
நநநநநநந நநநநநநநநநநநநநந நநநநநநநந நநநநநந நநநநநநநநநநநநநநந நநநநநநநநநநநநநந.
நநநந நநநந நநநநநநந நநநநநந நநநநந நநநநநந நநநநநநநநந நநநநநநநநநநநநநந நநநநநநநந
நநநநநநநநநநநந நநநநநநந நநநநநநநநநந நநநநநநநந நநநநநநநநநநநந.

நநநநநநநநநந நநநநநநநநந நநநநநநநநநநநநநந நநநநநநநநந / நநநநநந நநநநநநநநந நநநநந:

நநநநநநநநநந நநநநந: நநநநநநநநநநநநநந நநநநந:
நநநந: _____________
நநநந: _____________