Republic of the Philippines
Department of Health
East Avenue Medical Center
INSTITUTIONAL ETHICS REVIEW BOARD
CONFIDENTIALITY AGREEMENT FORM FOR NON-MEMBERS REQUESTING TO ACCESS EAST
AVENUE MEDICAL CENTER IERB DOCUMENTS
(EAMC IERB FORM 4.3)
I, (Name, Surname) as a non-member of the East Avenue Medical Center Institutional Ethics Review
Board, understand that the documents I am given access to by the East Avenue Medical Center
Institutional Ethics Review Board are confidential. I shall use the information only for the purpose
indicated in this form and shall not duplicate, give or distribute these documents to any person(s) without
permission from the East Avenue Medical Center Institutional Ethics Review Board. Upon signing
this form, I agree to take reasonable measures and full responsibility to keep the information as
Confidential.
Requested document
Reason for request
Number of copies requested
RECIPIENT
Signature
Date:
Name
IERB MEMBER-SECRETARY
Signature
Date:
Name
“ISO Tayo..serbisyong de kalidad at siguraDOH”
Telephone No.: (632) 928.0611 local 739
Email Address: ierb.eamc@gmail.com