ETHICAL CLEARANCE APPLICATION FORM

NB: ATTACH ALL APPENDICES

SECTION 1: PERSONAL DETAILS

Full Name and Surname of Applicant

Title

Student Number

Institution

Existing Qualifications

Proposed Qualification for Project

Contact Details
Telephone number
Cellphone number
E-mail
Postal address

Research coordinator (MANCOSA)

Supervisor details
Name of Contact number Email Institution/ Qualification
Supervisor department

SECTION 2: PROJECT DESCRIPTION

1
Please do not provide your full research proposal here: what is required is a short project
description of not more than two pages that gives, under the following headings, a brief overview
spelling out the background to the study, the key questions to be addressed, the participants (or
subjects) and research site, including a full description of the sample, and the research approach/
methods.
Project Title

Location of the study (where will the study be conducted.)

Study objectives and need for the study

1. Objectives

2. The need for the study

(Must include referenced background context, the problem to be addressed and the significance of the study)

3. Questions to be answered in the research

Research approach/ methods (This section should explain how you will go about answering the
critical questions which you have identified above. Set out the approach within which you will work
and indicate in step-by-step point form the methods you will use in this research in order to answer the
critical questions).

Proposed work plan (Set out your intended plan of work for the research, indicating important target
dates necessary to meet your proposed deadline.)
Step Date

SECTION 3: ETHICAL ISSUES YES NO

Does your study cover research involving:

2
Children
Persons who are intellectually or mentally impaired
Persons who have experienced traumatic or stressful life circumstances
Persons who are HIV positive
Persons highly dependent on medical care
Persons in dependent or unequal relationships
Persons in captivity
Persons living in particularly vulnerable life circumstances

If “Yes” indicate what measures, you will take to protect the autonomy of respondents and (where
indicated) to prevent social stigmatisation and/or secondary victimisation of respondents. If you are
unsure about any of these concepts, please consult your supervisor/ project leader.

Will data collection involve any of the following: YES NO

Access to confidential information without prior consent of participants
Participants being required to commit an act which might diminish self-respect or
cause them to experience shame, embarrassment, or regret
Participants being exposed to questions which may be experienced as stressful or
upsetting, or to procedures which may have unpleasant or harmful side effects
The use of stimuli, tasks or procedures which may be experienced as stressful,
noxious, or unpleasant
Any form of deception

If “Yes” explain and justify. Explain too what steps you will take to minimize the potential
stress/harm.

Will any of the following instruments be used for purposes of data YES NO
collection:
Interview Guide (Semi-structured)
Survey schedule
Interview schedule (one on one interview,)
Observation Schedule
Psychometric test
Other

3
If “Yes”, attach copy of research instrument. If data collection involves the use of a psychometric test
or equivalent assessment instrument, you are required to provide evidence here that the measure is
likely to provide a valid, reliable, and unbiased estimate of the construct being measured. If data
collection involves interviews and/or focus groups, please provide a list of the topics to be covered/
kinds of questions to be asked.

Will the autonomy of participants be protected through the use of an informed YES NO
consent form, which specifies (in language that respondents will understand):
The nature and purpose/s of the research
The identity and institutional association of the researcher and supervisor/project leader
and their contact details
The fact that participation is voluntary
That responses will be treated in a confidential manner
Any limits on confidentiality which may apply
That anonymity will be ensured where appropriate (e.g. coded/ disguised names of
participants/ respondents/ institutions)
The fact that participants are free to withdraw from the research at any time without any
negative or undesirable consequences to themselves
The nature and limits of any benefits participants may receive as a result of their
participation in the research
Is a copy of the informed consent form attached?
If not, this needs to be explained and justified, also the measures to be adopted to ensure that the
respondents fully understand the nature of the research and the consent that they are giving.

Specify what efforts been made or will be made to obtain informed permission for the research
from appropriate authorities and gatekeepers (including caretakers or legal guardians in the case
of minor children)?

In the subsequent dissemination of your research findings – in the form of the finished thesis,
oral presentations, publication etc. – how will anonymity and confidentiality be protected?

4
Is this research supported by funding that is likely to inform or impact in any YES NO
way on the design, outcome, and dissemination of the research?
If yes, this needs to be explained and justified.

SECTION 4: FORMALISATION OF THE APPLICATION APPLICANT

I, the undersigned, hereby declare that the information supplied above is correct to the best of my
knowledge.

___________________________________
SIGNATURE OF APPLICANT
DATE:

RESEARCH ETHICS SUB-COMMITTEE RECOMMENDATION

DESIGNATION SIGNATURE DATE

Research Supervisor

Research Coordinator

5
 Postgraduate Research Manager

Honours Research Manager

Research Director

ATTACH ALL APPENDICES

CHECK SHEET FOR ETHICAL CLEARANCE (PLEASE TICK)

1. Form has been fully completed and all questions have been answered ☐
2. Questionnaire attached (where applicable) ☐
3. Informed consent document attached (where applicable) ☐
4. Approval from relevant authorities obtained (and attached) where research involves the ☐
utilization of space, data and/or facilities at other institutions/organisations
5. Signature of Supervisor / project leader ☐
6. Application forwarded to Faculty Research Committee for recommendation and transmission ☐
to the Research Office