Parsottam Mamorial Trust (PMT) · Varanasi, U.P.

Research Certification Application

Ethical Committee & Research Review Board (ECRRB)

Researchers seeking ethical clearance / certification from the ECRRB for a research proposal, study, or published paper should complete this form. Please keep your protocol/synopsis, informed consent documents, CV, and any prior approvals ready to upload before you begin. Fields marked * are required.

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Principal Investigator Details

Full Name*

Required.

Designation*

Required.

Department / Institution / Organization*

Required.

Email Address*

Please enter a valid email.

Phone Number*

Required.

Co-Investigator(s) / Team Members

Name(s), designation, and affiliation — one per line.

ORCID / Scopus Author ID (if any)

Proposal / Research Paper Details

Title of Study / Research Paper*

Required.

Nature of Submission*

Please select an option.

Type of Research*

Please select an option.

Proposed / Actual Start Date*

Required.

Expected Duration*

Required.

Study Site(s) / Location(s)

Journal Name (if submitted/published) or Target Journal

Objectives & Methodology

Objectives of the Study*

Required.

Brief Summary of Methodology*

Study design, data collection tools/instruments, and analysis plan.

Required.

Study Population*

Required.

Sample Size*

Required.

Inclusion / Exclusion Criteria

Does the study involve any vulnerable population?*

e.g., children, persons with cognitive impairment, economically/socially disadvantaged individuals.

Yes

Please select an option.

If yes, describe the safeguards proposed

Ethical Considerations

Anticipated Risks to Participants*

Required.

Anticipated Benefits (to participants / society)*

Required.

Informed Consent Process*

How and when consent will be obtained; language(s) used; provision for withdrawal.

Required.

Confidentiality & Data Handling*

How participant data/identity will be protected, stored, and eventually disposed of or archived.

Required.

Compensation / Incentive to Participants (if any)

Funding & Conflict of Interest

Is this study funded?*

Yes

No / Self-funded

Please select an option.

Name of Funding Agency / Sponsor (if applicable)

Conflict of Interest Declaration*

I declare that I have no undisclosed conflict of interest (financial, professional, or personal) relating to this study

Please confirm this declaration.