For Graduate students, Faculty of Graduate Studies, Mahidol University
Document No. 1b
Faculty …………………………………….
Document no. Sor Thor …………………………………….
Date …………………………………….
Re : Request an assistance to conduct research
Dear Dean of the Faculty of MedicineSiriraj Hospital,
Mr./Mrs./Miss ……………………………………., a graduate student from the Faculty of Graduate Studies,
Mahidol University, curriculum ……………………………………., subject area …………………………………., Faculty
……………………………………., is conducting a thesis titled “…………………………………….” under the supervision
of …………………………………….. The student is required to compile the data on …………………………………….
at ……………………………………. by using the method ……………………………………. from
……………………………………. to …………………………………….
I have attached the protocol and the following document listed below for your consideration. (In case of
expedited/exemption review, please provide document no. 1d as well)
1 Curriculum vitae of supervisor, student, and all co-investigator
4
sets
2 SIRB Submission form (Thai)
4
sets
3 Research protocol (Thai)
4
sets
4 Research protocol (English)
4
sets
5 Participant information sheet
4
sets
6 Informed consent form
4
sets
7 Case record form
4
sets
8 Questionnaire
4
sets
9 Investigator’s brochure/drug leaflet or medical device registration
4
sets
10 Certificate of thesis proposal examination
4
sets
11 Permission form to use patient’s medical record /specimen in research 4
sets
12 CD containing information of document no. 1-9
1
sets
13 Other, please specify ………………………………….
4
sets
Remark Four sets of document consist of one original andthree copies.
Thank you for your kind consideration.
Yours sincerely,
Signature ……………………………………………………
(……………………………………)
Dean of the Faculty of Graduate Studies, Mahidol University
or representative