F/BERC 1 (2021)

Faculty/Branch Ethics Review Committee

Universiti Teknologi MARA

Ethics Approval Application Form for Undergraduates or

Postgraduates by Coursework
Borang Permohonan Kelulusan Etika bagi Pelajar Sarjana Muda atau
Pasca Siswazah Kerja Kursus

This application is for the purpose of obtaining approval to conduct research.

Please attach a copy of Research Proposal.
Permohonan ini dikemukakan untuk tujuan kelulusan menjalankan penyelidikan.
Sila lampirkan salinan kertas cadangan penyelidikan.

Part A : Details of Researcher

Bahagian A: Maklumat Penyelidik

Title of Research Title should contain the independent variable,

Project : dependent variable and population. Do not exceed 15
Tajuk Penyelidikan : words
Researcher can be undergraduate student/ postgraduate
Name of Researcher* : student/ staff or external applicant
Nama Penyelidik*:

Name of Supervisor :
Nama Penyelia:

Address of Department/
Institute :
Alamat Jabatan/ Institut :

Contact No/ Email :

No.Telefon/ Emel :

Undergraduate / Sarjana Muda

Postgraduate by Coursework/ Pasca Siswazah Kerja Kursus

Does the research require an external Research Ethics Committee approval? (e.g.
MREC)
Adakah penyelidikan ini memerlukan kelulusan Jawatankuasa Etika Penyelidikan Luaran?
(contoh MREC)

Yes / Ya External Committee Name: Select (tick) “Yes” if the study

No / Tidak involves premises governed by
external bodies (eg. Studies
conducted at the Ministry of
Health hospitals require approval
of the Medical Research Ethics
Research funding: Yes/ No Committee (MREC). Provide the
Dana Penyelidikan: Ada/ Tiada
name of the external Research
If obtained, please complete section C. Ethics Committee.
Jika ada, sila lengkapkan bahagian C.

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Part B : Research Details

Bahagian B: Maklumat Penyelidikan

Part B1
Bahagian B1
Interviews Case study
Temubual Kajian kes

Focus groups Intervention study

Kumpulan focus Kajian intervensi

Questionnaires Personal records

Soal selidik Rekod peribadi

Action research Secondary data analysis

Kajian tindakan Analisis data sekunder

Observation Others (provide details):

Pemerhatian Lain-lain (nyatakan):

Part B2
Bahagian B2
1. Background:
Latar belakang:
(A brief explanation of the problem to be studied and literature review to support.
Please append if more space is required)
(Keterangan ringkas tentang masalah yang dikaji dan penyemakan literatur untuk
menyokong keterangan tentang masalah yang dikaji. Sila lampirkan sekiranya ruang tidak
mencukupi)

Briefly describe the study. The description should include the independent variable,
dependent variable and the population

Problem statement:
Penyataan masalah:

References:
Rujukan: Include only references cited in the Background Section

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2. Research objectives:
Objektif penyelidikan:

Should be numbered. Use measurable verbs (eg. to compare, to measure etc.)

3. Expected benefits:
Faedah yang dijangka:

Briefly describe social benefits to the study subjects/researchers/stakeholders, and

expansion of the existing knowledge

4. Date of research commencement-end: Date should be after REC approval.

Tarikh penyelidikan bermula-berakhir: Allow at least 1 month interval from
For undergraduates studies, at least two semesters the
or date
untilofthe studydocument
complete is completed.
(eg: March 2022 – February 2023) submission (eg. if completed
documents are submitted in March
2022, expected date of initial data
collection should be in May 2020)
5. Expected date of initial data collection:
Jangkaan tarikh pengumpulan data bermula:

6. Location of research:
Lokasi penyelidikan dijalankan:

Location should be specific (eg: Faculty of Sports Science, UiTM Shah Alam,
Dataran Kemerdekaan etc.)

7. Research design dan methodology:

Rekabentuk penyelidikan dan metodologi:

Specify the study design (eg. cross sectional/ experimental) Describe the
methodology i.e. data collection procedure, tools etc. (eg. in a questionnaire-based
study describe the number of domains, number of items and scoring of the
questionnaire)

8. Inclusion and exclusion criteria:

Kriteria kemasukan dan pengecualian: Characteristics of the samples/
respondents to be included and
Inclusion criteria:
excluded from the study
Kriteria kemasukan:


Exclusion criteria:
Kriteria pengecualian:


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9. Sample size:
Saiz sampel: Indicate the sample size (taking into
consideration dropout/attrition rates. Provide the
calculation for sample size. If the calculation is
based on a previous study, please cite and attach
Pengiraan: the reference.
Calculation:

10. Research flowchart: Explain whether descriptive or inferential

Carta alir penyelidikan:
statistics will be used. If inferential,
explain the type of statistical test to be
used (eg T-test, ANOVAetc.)
11. Statistical analysis:
Analisa statistik:

* If not applicable please write ‘-NA-’ in the spaces provided.

Jika tiada kaitan sila tulis ‘-NA-’ di ruangan disediakan .
If the study is funded, please
Part C: Funding details provide details. If the study is
Bahagian C: Maklumat Dana
not funded, please state “Not
1. Grant / Source: Applicable” (NA)
Geran / Sumber:

2. Date of grant approval:

Tarikh kelulusan geran:

3. Total allocation:
Jumlah peruntukan:

4. Duration of grant:
Jangkamasa peruntukan:

5. Others:
Lain-lain:

Part D: Agreement to conduct the research project.

Bahagian D: Pengesahan persetujuan menjalankan penyelidikan.

Must be completed and signed by all members of the research group.

Mesti dilengkapkan dan ditandatangani oleh semua ahli kumpulan penyelidikan.

1. Applicant (to be filled by Undergraduate/Post-graduate by Coursework Student

only)
Pemohon (untuk dilengkapkan oleh Pelajar Siswazah / Pasca-siswazah Kerja
Kursus sahaja)
Name:
Nama:
Staff ID/Student ID:
No.Staf/No. Pelajar:
Position/
Specialisation:

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Jawatan/ Kepakaran:
Affiliation:
Jabatan:
Office:
Telefon pejabat:
Mobile phone: Telefon
bimbit:
Email:
Emel:
Signature: Date:
Tandatangan: Tarikh:

2. Supervisor
Penyelia

Name:
Nama:
Staff ID/Student ID:
No.Staf/No. Pelajar:
Position/
Specialisation:
Jawatan/ Kepakaran:
Affiliation:
Jabatan:
Office:
Telefon pejabat:
Mobile phone: Telefon
bimbit:
Email:
Emel:
Signature: Date:
Tandatangan: Tarikh:

3. Penyelidik Bersama
Co-Researcher

Name:
Nama:
Staff ID/Student ID:
No.Staf/No. Pelajar:
Position/
Specialisation:
Jawatan/ Kepakaran:
Affiliation:
Jabatan:
Office:
Telefon pejabat:
Mobile phone: Telefon
bimbit:
Email:
Emel:
Signature: Date:
Tandatangan: Tarikh:

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(Add if necessary. Tambah sekiranya perlu.)

Please answer each item in the

form by selecting (ticking) the
option that applies. If “Yes” is
selected, please describe details
Part E: Research Risk Classification of risk and how the risk is
Bahagian E: Klasifikasi Risiko Kajian minimized
PLEASE ANSWER ALL QUESTIONS BELOW.
If your answer is ‘Yes’ to any of the following questions, please include a brief
information in the space provided.

SILA JAWAB KESEMUA SOALAN DI BAWAH.

Sekiranya jawapan anda ‘Ya’ kepada mana-mana soalan di bawah, sertakan maklumat
ringkas di ruang yang disediakan.

PARTICIPANT PROFILE No Yes Brief description

1. Are the participants children (under 18
years old)?
Adakah peserta kanak-kanak (Umur di
bawah 18 tahun)?
2. Are the participants from a particular
vulnerable group? (e.g. mental
disorder, mentally challenged,
disabled, minority, disadvantaged
group etc.)
Adakah peserta daripada golongan
rentan? (cth: kecelaruan mental, kelainan
keupayaan intelektual, berkeperluan
khas, minoriti dan sebagainya.)
3. Are any of these participants/patients
in terminal care?
Adakah peserta/pesakit ini memerlukan
rawatan terminal?
4. Are any of these participants unable
or are incapable of giving consent?
(i.e. consent will be obtained indirectly
from a legal guardian etc.)
Adakah peserta tidak boleh atau tidak
berupaya memberi izin?
(spt: izin akan diambil secara tidak
langsung daripada penjaga sah dan
sebagainya.)
5. Are the participants given any form of
emolument to participate?
Adakah peserta diberi sebarang
emolumen untuk menyertai kajian?
PRIVACY AND CONFIDENTIALITY No Yes Brief description
6. Does any of the data collected have
the potential to cause discomfort,
embarrassment, or psychological
harm to the participants?
(e.g. sexual orientation etc.)
Adakah data yang dikumpul berpotensi

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untuk menyebabkan ketidak selesaan,

keaiban atau gangguan psikologi kepada
peserta? (cth: orientasi seksual dan
sebagainya.)
7. Does your research involve measures
undeclared to the participants?
(e.g. covert observations etc.)
Adakah penyelidikan anda melibatkan
langkah-langkah yang tidak dimaklumkan
kepada peserta?
(cth: pemerhatian rahsia dan sebagainya.)
8. Will the collected data be made
available to other parties not involved
in the research? (e.g. government
agencies)
Adakah data yang dikumpulkan akan
didedahkan kepada pihak lain yang tidak
terlibat dalam penyelidikan? (cth. agensi
kerajaan)
RISK OF HARM No Yes Brief description
9. Will you be collecting biological
samples e.g. body fluids?
Adakah anda akan mengumpul sampel
biologi contohnya. cecair badan?
10. Do you have access to any
information that will allow the
identification of individual human
participants?
Adakah anda mempunyai akses kepada
apa-apa maklumat yang akan
membolehkan pengenalpastian peserta
secara individu?
11. Is the collection method invasive and
has the potential to cause harm, pain
or discomfort?
(except finger, heel, ear prick.)
Adakah kaedah pengumpulan invasif dan
berpotensi menyebabkan kemudaratan,
kesakitan atau ketidakselesaan?
(kecuali tusukan jari, tumit, telinga.)
12. Will the participants be subjected to
vigorous physical tests or exercise
regime?
(if ‘No’, go to Question 15.)
Adakah peserta akan melalui ujian fizikal
atau senaman berintensiti tinggi?
(jika 'Tidak', teruskan ke Soalan 15.)
13. Are the participants non-athletes or
patients with chronic illness?
Adakah peserta bukan atlet atau pesakit
dengan penyakit kronik?
14. Will they be subjected to maximal
exercise intensity?
Adakah mereka akan melalui senaman
berintensiti maksimum?
15. Is there any form of procedure/
medication involved?
Adakah terdapat sebarang prosedur/ ubat

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yang terlibat?
16. Is there any drug or device used with
an unapproved indication?
Adakah terdapat ubat atau peranti yang
digunakan dengan tanpa indikasi yang
diluluskan?
17. Can the informed consent be obtained
from anyone other than the
patient/participants?
Adakah keizinan kajian telah didapati
daripada sesiapa selain pesakit/peserta?
18. Is there any kind of risk to the
participants if he/she chose to
withdraw?
Adakah terdapat sebarang kemudaratan
kepada peserta jika dia memilih untuk
menarik diri?
19. Will the samples obtained be stored
for future research?
Adakah sampel yang dikumpul akan
disimpan untuk penyelidikan di masa
hadapan?
20. Do you propose to analyse the sample
outside of the original purpose for
which it was collected?
Adakah anda bercadang untuk
menganalisa sampel selain tujuan asal ia
dikumpulkan?
21. If ‘Yes’ to No. 20, have you obtained
consent from participants for this
purpose?
Jika 'Ya' pada No. 20, adakah anda
mendapat persetujuan daripada peserta
untuk tujuan ini?
22. What type of biological samples
collected?
(Please indicate amount and
frequency.)
Apakah jenis sampel biologi yang
dikumpul?
(Sila nyatakan jumlah dan kekerapan.)

OTHER ETHICAL ISSUES No Yes Brief description

23. Are there any other ethical issues not
stated in this checklist?
Adakah terdapat sebarang isu etika lain
yang tidak dinyatakan dalam senarai
semak ini?

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Part F: Applicant Checklist PLEASE READ THIS

Bahagian F: Senarai Semak Pemohon

Terms of Submission of Ethics Approval Application

1. Please ensure that all research team members have signed the application.
2. Please ensure that the application has been signed and endorsed by the
Department or Postgraduate Research Sub-Committee.
3. All required documents must be submitted within two (2) months before the
data collection.
4. Submission of all forms prescribed by the REC must be in English, with
exception to research conducted in other languages (with Senate
approval).
5. Any data collection instruments that require completion by
respondents/participants must be prepared in the Malay and English
languages, and other language(s) understood by the participants.

ITEM YES NO
PERKARA YA TIDAK
Part A – For All Applicants
Bahagian A – Untuk Semua Pemohon
1 Have you presented your proposal at the Department or
Postgraduate Research Sub-Committee?
Adakah anda telah membentangkan proposal anda di
Jawatankuasa Kecil Penyelidikan Jabatan atau Pascasiswazah?
2 Have you completed the F/BERC 1 form?
Adakah anda telah melengkapkan Borang F/BERC 1?
3 Have you completed the F/BERC 2 or and F/BERC 3 form?
Adakah anda telah melengkapkan Borang F/BERC 2 atau dan
borang F/BERC 3?
4 Has your supervisor checked your application forms?
Adakah penyelia anda telah menyemak borang permohonan
anda?
5 Has the form been signed by all researchers?
Adakah borang ditandatangani oleh semua penyelidik?
6 Has your application been endorsed by the Department or
Postgraduate Research Sub-Committee?
Sudahkah permohonan anda mendapat pengesahan
Jawatankuasa Kecil Penyelidikan Jabatan atau Pascasiswazah?

Additional comments (if any):

Komen Tambahan (Jika Ada):

Applicant’s Signature Date

Supervisor’s Signature Date

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Part G: Verification from Department or Postgraduate Research Sub-

Committee
Bahagian G: Pengesahan Jawatankuasa Kecil Penyelidikan Jabatan atau
Pascasiswazah

We have deliberated on the application and propose as below:

Kami telah meneliti permohonan ini dan mencadangkan seperti di bawah:

Minimal risk research. Recommend for approval without presentation.

Penyelidikan melibatkan risiko minima. Dicadangkan untuk mendapat kelulusan
tanpa pembentangan.

More than minimal risk research. Recommend to forward to UiTM REC.

Penyelidikan melibatkan risiko melebihi minima. Dicadangkan untuk dihantar kepada
UiTM REC.

Comment if any:
Ulasan jika ada:

Signature Tandatangan: Official stamp: Date:

Coordinator of Committee Cop rasmi: Tarikh:
Koordinator Jawatankuasa

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