YAYASAN KARYA HUSADA KEDIRI

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

AS
STIKES KARYA HUSADA KEDIRI Y A YE D I R AI N
K
Ijin Mendiknas RI No. 164/D/O/2005
LEMBAGA PENELITIAN DAN PENGABDIAN MASYARAKAT
(LPPM)

K A

A
R Y
A H U SA

D
Jl. Soekarno Hatta No. 07 Telp. (0354) 399912 Fax 393888 Pare Kediri
Website : www.stikes-khkediri ac.id

DATA PEMOHON TELAAH ETIK PENELITIAN

Nama : ..................................................................................................................................................
Alamat : ..................................................................................................................................................
..................................................................................................................................................
Telepon/HP : ..................................................................................................................................................
Penelitian :
 S1  Dosen

 D4  PKM mahasiswa

 D3  Lain – Lain : ...........................................................................

Program Studi : ..................................................................................................................................................

Judul Penelitian : ..................................................................................................................................................

..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
Pembimbing I : ..................................................................................................................................................
Pembimbing II : ..................................................................................................................................................
Tempat Penelitian : ..................................................................................................................................................

“Dengan ini saya menyatakan bahwa materi penelitian yang saya ajukan untuk dilakukan telaah etik penelitian
pada Komisi Etik Penelitian STIKES Karya Husada Kediri, adalah benar – benar penelitian yang belum pernah
dilaksanakan, dan apabila penelitian saya terbukti PLAGIARISME, Saya bersedia
kelayakan etik penelitian ini dibatalkan”.

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

______________________________

YAYASAN KARYA HUSADA KEDIRI

AS
Keputusan Menkumham RI No. AHU-5902.AH.01.04.Tahun 2011 Y A YE D I R AI N
K
K A

R Y
A H U SA
D
 STIKES KARYA HUSADA KEDIRI
Ijin Mendiknas RI No. 164/D/O/2005
LEMBAGA PENELITIAN DAN PENGABDIAN MASYARAKAT
(LPPM)
Jl. Soekarno Hatta No. 07 Telp. (0354) 399912 Fax 393888 Pare Kediri
Website : www.stikes-khkediri ac.id

BERITA ACARA
PELAKSANAAN TELAAH ETIK PENELITIAN
STIKES KARYA HUSADA KEDIRI

Pada hari ini, .................... tanggal ..................... bulan ....................... tahun dua ribu delapan belas bertempat
di STIKES Karya Husada Kediri telah dilaksanakan oleh :

Nama : ...............................................................................................................................................
NIM : ..............................................................................................................................................
Prodi : ..............................................................................................................................................
Judul : ..............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

Hasil Telaah :

…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………
……………………………………………………………….............................................................................................
...........................
…………………………………………………………………………………………………………...................................
...................................................................................................................................................................................
......

Reviewer/Penguji :

1. …………………………………………....................................

(........................……………….)
 YAYASAN KARYA HUSADA KEDIRI
Keputusan Menkumham RI No. AHU-5902.AH.01.04.Tahun 2011
AS
STIKES KARYA HUSADA KEDIRI Y A YE D I R AI N
K
Ijin Mendiknas RI No. 164/D/O/2005
LEMBAGA PENELITIAN DAN PENGABDIAN MASYARAKAT
(LPPM)

K A

A
R Y
A H U SA

D
Jl. Soekarno Hatta No. 07 Telp. (0354) 399912 Fax 393888 Pare Kediri
Website : www.stikes-khkediri ac.id

BERITA ACARA REVISI

TELAAH ETIK PENELITIAN

Nama : ......................................................................................................................................
NIM : ......................................................................................................................................
Judul Penelitian : ......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Reviewer I : ......................................................................................................................................

Tanggal Telaah : ......................................................................................................................................

PARAF
NAMA REVIEWER MATERI REVISI
REVIEWER
 YAYASAN KARYA HUSADA KEDIRI
Keputusan Menkumham RI No. AHU-5902.AH.01.04.Tahun 2011
AS
STIKES KARYA HUSADA KEDIRI Y A YE D I R AI N
K
Ijin Mendiknas RI No. 164/D/O/2005
LEMBAGA PENELITIAN DAN PENGABDIAN MASYARAKAT
(LPPM)

K A

A
R Y
A H U SA

D
Jl. Soekarno Hatta No. 07 Telp. (0354) 399912 Fax 393888 Pare Kediri
Website : www.stikes-khkediri ac.id

BERITA ACARA REVISI

TELAAH ETIK PENELITIAN

Nama : ......................................................................................................................................
NIM : ......................................................................................................................................
Judul Penelitian : ......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Reviewer II : ......................................................................................................................................

Tanggal Telaah : ......................................................................................................................................

PARAF
NAMA REVIEWER MATERI REVISI
REVIEWER