research application form universiti kebangsaan malaysia medical ...

MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
RESEARCH APPLICATION FORM
UNIVERSITI KEBANGSAAN MALAYSIA MEDICAL CENTRE
1. APPLICANT
A. NAME: ……………………………………………………………………………………………………….
B. ID NO. : ………………………………………………………….
C. DEPARTMENT: …………………………………………………………………………………………..
D. OTHER RESEARCHER(S):
Name ID/Matric. No Department
1) .………………………………………………………………… ……………………………… ………………………………
2) …………………………………………………………………. ……………………………… ………………………………
3) …………………………………………………………………. ……………………………… ………………………………
2. RESEARCH PROJECT: (Summary of proposal)
A Research proposal must be attached to this form. The proposal must have a title, background
of the research with current references, objective(s), Gannt chart, the required infrastructure,
methodology and the estimated budget. Please enclose the sabbatical / study leave approval
letter; if applicable
A. TITLE:
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
B. OBJECTIVE(S):
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
C. DURATION: (not more than 3 years)
Date of commencement : [ ] [ ] [ ]
Date of completion : [ ] [ ] [ ]
D. TYPE OF RESEARCH PROJECT:
[ ] *Undergraduate/Masters/PhD
[ ] Sabbatical Leave
[ ] Practicum
[ ] Others (Please state)
…………………………………………………………………………………………………………………
E. FIELD:
[ ] Fundamental
[ ] Industry
[ ] Biotechnology
[ ] Technology - manufacturing/innovation/electronic/information/others
(Please state): ………………………………………………………………………….
[ ] Health/medical
[ ] Others (Please state): ……………………………………………………………..
3. Research scope:
[ ] Drug Trial
[ ] Clinical Trial
[ ] Theory
[ ] Field Work
[ ] Lab Work
[ ] Questionnaire
[ ] Others (Please state): ……………………………………………………………………………
*Please strikethrough which are not applicable
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
4. EXTERNAL SPONSOR/GRANT :
Item
Total (RM)
Total: …………………………………………………………..
** Please enclosed endorsement from company
*Please leave out the page on “FINANCIAL ESTIMATION AND JUSTIFICATIONS FOR RESEARCH
PROJECT” if this research is sponsored externally.
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
………………………………………………..
Applicant Signature
………………………………….
Date
5. ENDORSEMENT: (Application must be screened at department level first before endorsement)
A. Recommendation by Head of Department/Unit/Division
……………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….
Recommended budget : RM …………………………………………….
……………………………………………..
Signature & Stamp
…………………………………
Date
B. Decision of Faculty/Centre/Institute Research Committee
…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….
C. Approved Budget : RM …………………………………………..
…………………………………………….
Signature & Stamp
…………………………………
Date
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
Not applicable to externally sponsored research
FINANCIAL ESTIMATION AND JUSTIFICATION FOR RESEARCH PROJECT
PORTION OF BUDGET: RESEARCH MATERIAL & SUPPLY
MAIN ITEM
[1]
JUSTIFICATION
[2]
AMOUNT OR QUANTITY
[3]
TOTAL (RM)
[4]
TOTAL RM :
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
FINANCIAL ESTIMATION AND JUSTIFICATION FOR RESEARCH PROJECT
PORTION OF BUDGET: TRAVELLING AND TRANSPORTATION
TYPE OF TRANSPORTATION
AND TRAVELLING
[1]
PURPOSE
[2]
REGULARITY
[3]
TOTAL (RM)
[4]
TOTAL RM :
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
FINANCIAL ESTIMATION AND JUSTIFICATION FOR RESEARCH PROJECT
PORTION OF BUDGET: SPECIAL EQUIPMENTS AND ACCESSORIES
MAIN ITEM
[1]
JUSTIFICATION
[2]
AMOUNT OR QUANTITY
[3]
TOTAL (RM)
[4]
TOTAL RM :
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MEDICAL RESEARCH & INDUSTRY SECRETARIAT
SEKRETARIAT PENYELIDIKAN PERUBATAN & INDUSTRI
AGREEMENT FORM
CO-RESEARCHER/CO-SUPERVISOR
I hereby agree to take part in this research as a co-researcher / co-supervisor:
Name
Designation
Date
: _______________________________________
: _______________________________________
: ______________
Signature : _________________________
Department Official Stamp:
Name
Designation
Date
: _________________________
: _________________________
: ______________
Signature : _________________________
Department Official Stamp:
Name
Designation
Date
: _________________________
: _________________________
: ______________
Signature : _________________________
Department Official Stamp:
Name
Designation
Date
: _________________________
: _________________________
: ______________
Signature : _________________________
Department Official Stamp:
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