MAULANA AZAD MEDICAL COLLEGE

MAULANA AZAD MEDICAL COLLEGE
And
Associated Lok Nayak, Govind Ballabh Pant Hospital,
Guru Nanak Eye Centre, New Delhi –110 002
(Institutional Ethics Committee)
F. No./11/IEC/MAMC/2011/ Dated:
ETHICAL CLEARANCE CERTIFICATE
Subject: Reference Thesis / Protocols submitted by Dr. ___________________________
To,
___________________, MD/MS ____________________________________________.
The Sub Committee constituted by Institutional Ethics Committee, MAMC has reviewed and
discussed your protocol on___________ to conduct the Research Project entitled “
____________________________________________________________________
____________________________________________________________________”
After consideration, the committee has decided to approve the study under the
referenced protocol subject to the following condition:-
� It is understood that the study is being conducted at Maulana Azad Medical Collage &
Associated Lok Nayak Hospital ,Govind Ballabh Pant Hospital and Guru Nanak Eye Centre,
Bahadur Shah Zafar Marg, New Delhi – 110 002.
� Any Serious Adverse Event that occurs during the conduct of the study at Maulana Azad
Medical Collage & Associated Lok Nayak Hospital ,Govind Ballabh Pant Hospital and Guru
Nanak Eye Centre, Bahadur Shah Zafar Marg, New Delhi - 110002, should be reported to
the Ethics Committee immediately.
� The Study will be conducted after informed consent from patient/guardian
Dr.___________________
Supervisor: Dr.______________________________
Department of ___________________
(Dr. M.M. MEHNDIRATTA)
Member Secretary
Institutional Ethics Committee

GOVERNMENT OF NCT OF DELHI
MAULANA AZAD MEDICAL COLLEGE
2-BAHADUR SHAH ZAFAR MARG: NEW DELHI-02
INFORMED CONSENT FORM
I _______________________________ S/D/W of________________________________
R/O__________________________________________________________________________
_____________________________________________________________________________
do hereby declare that I give informed consent to participate in the Thesis study entitled
“___________________________________________________________________________
___________________________________________________________________________”
Dr.______________________________ has informed me to my full satisfaction, in the
language I understand, about the purpose, nature of study and various investigations to be
carried out for the study. I have been informed about the duration of study & possible
complication caused by study.
I give full consent for being enrolled in the above study and I reserve my rights to withdraw
from the study whenever I wish without prejudice of my right to undergo further treatment at
this Hospital and its Associated Hospital.
Signature of patient
Signature of relative
Name: Date:
We have witnessed that the patient signed the above from in the presence of his/her free will
after fully having understood its contents.
Signature of witness Signature of Investigator
Name Name
Relation

GOVERNMENT OF NCT OF DELHI
MAULANA AZAD MEDICAL COLLEGE
2-BAHADUR SHAH ZAFAR MARG: NEW DELHI-02
INFORMED CONSENT FORM (for Paediatrics Deptt)
I ____________________________ Father/Mother of __________________, a resident of
_______________________________________________, hereby declare that I give informed
consent to allow my child to participate in the Thesis study labeled
“___________________________________________________________________________
___________________________________________________________________________”
Dr.______________________________ has informed me to my full satisfaction, in the
language I understand, about the purpose, nature of study and various investigations to be
carried out for the study. I have been informed about the duration of study & possible
complication caused by study.
I give full consent for my child being enrolled in the above study and including tests
and I reserve my rights to withdraw the child from the study whenever I wish without
prejudice of my child’s right to undergo further treatment at this Hospital and its Associated
Hospital.
Signature of parent/guardian
Name: Date:
We have witnessed that the parent/guardian signed the above from in the presence of his free
will after fully having understood its contents.
1. 2.
Signature of witness Signature of staff
Name Name
Relation Designation
Signature of Investigator
Name:

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