Epidemiological Study Ethics Committee Approval Form

1. Study Information

Study Title Study Objective Principal Investigator Name Institution Contact Information

2. Study Design

Study Design Study Duration Study Location(s)

3. Participants

Target Population Sample Size Inclusion Criteria Exclusion Criteria

4. Ethical Considerations

Informed Consent Process Assessment of Risks and Benefits Data Confidentiality Measures

5. Investigator/Team Members

Name	Role	Contact Information

6. Declaration

I, hereby declare that all information provided in this form is accurate and complete. Date

7. Ethics Committee Use Only

Review Comments Approval Status Approved Conditionally Approved Not Approved Reviewer Signature Date