YAYASAN KARYA HUSADA KEDIRI

Keputusan Menkumham RI No. AHU-5902.AH.01.04.Tahun 2011 AS

Y A YE D I R AI N
STIKES KARYA HUSADA KEDIRI K
Ijin Mendiknas RI No. 164/D/O/2005
KOMISI ETIK PENELITIAN
Jl. Soekarno Hatta No. 07 Telp. (0354) 399912 Fax 393888 Pare Kediri

K A

A
R Y
Website : www.stikes-khkediri ac.id A H U SA

D
KETERANGAN KELAIKAN ETIK

Nomor : ........../EC/LPPM/STIKES/KH/......./2018

Setelah Tim Etik Penelitian mempelajari dengan seksama rancangan penelitian yang diusulkan, :

Judul proposal :
…………………………………………………………………………………………………………………
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………………………………………………………………………………................................................
Peneliti : ......................................................................................................................
Prodi : .....................................................................................................................
Tempat Penelitian : .....................................................................................................................

Maka dengan ini menyatakan bahwa penelitian tersebut telah memenuhi syarat laik etik.

Kediri, .......................................... 2018

Komisi Etik Penelitian
Ketua,

Dwi Setyorini, S.Kep.Ns.,M.Biomed

NIDN : 07-0404-8101
 FORMULIR ETIK PENELITIAN KESEHATAN

ANIMAL RESEARCH

Nama pembimbing :

1.
2.

Nama peneliti

1.

1. Tujuan :
o Penelitian
o Pelatihan/ training
o Pembiakan
o Lain-lain : ...............................................................................................................
2. Waktu penelitian :
.........................................................................................................................................
3. Data hewan coba :
Spesies : .......................................................................................................
Umur : .......................................................................................................
Jenis kelamin : .......................................................................................................
Berat : .......................................................................................................
Jumlah : .......................................................................................................

4. Masalah etik yang mungkin akan dihadapi :

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5. Prosedur penelitian (frekuensi perlakuan, dosis, dan tindakan) :
.........................................................................................................................................
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6. Bahaya potensial dan cara mengatasi kejadian tersebut (nyeri dan rasa sakit
pada hewan) :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
7. Pengalaman terdahulu (sendiri atau orang lain) dari tindakan yang akan
dilakukan :
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8. Bagaimana cara memilih hewan yang sehat?
.........................................................................................................................................
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9. Jika menggunakan hewan sakit jelaskan diagnosa dan siapa yang bertanggung
jawab merawatnya. Bila menggunakan hewan sehat jelaskan cara pemeriksaan
kesehatannya!
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10. Jelaskan cara pencatatan selama penelitian, termasuk efek samping dan
komplikasi bila ada!
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.........................................................................................................................................
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11. Bagaimana memperlakukan hewan coba bila ada gejala efek samping?
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12. Bagaimana cara mengamankan hewan agar tidak mengganggu lingkungan
sekitar?
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13. Hewan coba setelah dipergunakan, apakah dimusnahkan? Bagaimana cara
memusnahkan hewan coba?
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RINGKASAN USULAN PENELITIAN

 1. Pendahuluan yang memuat prevalensi dan justifikasi serta tujuan

penelitian.

2. Kerangka Konsep

3. Hipotesis bila ada

4. Metodologi Penelitian

a. Populasi dan Teknik Sampling

b. Penggunaan Uji Statistik bila ada

c. Definisi Operasional :

1). Variabel Penelitian

2). Definisi Operasional

3). Parameter

4). Skala data

5. SOP Intervensi/Perlakuan

6. Informed Consent

Kata kunci :

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Pernyataan dan tanda tangan

Yang bertanda tangan di bawah ini :

Nama : ..........................................................................................................

Jabatan : ..........................................................................................................

Bertindak sebagai : ..........................................................................................................

Judul penelitian : ..........................................................................................................

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...........................................................................................................

...........................................................................................................

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Telah membaca dan mengerti tentang isi informasi sekaligus mengisi formulir ini dan

bertanggungjawab terhadap pelaksanaan penelitian tersebut di atas.

Kediri, ...................................... 2018

Peneliti,