Banjarmasin, ..............................

Nomor :
Perihal : Pengajuan Etik Penelitian

Yang Terhormat
Ketua Komisi Etik
Universitas Muhammadiyah Banjarmasin

Sehubungan dengan akan dilaksanakannya penelitian saya, maka dengan ini mengajukan
permohonan untuk mendapatkan Ethical Clearance dari Komisi Etik Universitas
Muhammadiyah Banjarmasin, atas nama :

Nama :
NPM :
Program Studi :
Judul Penelitian :
Tempat :
Waktu :
Pembimbing : 1.
2.
Demikian permohonan ini saya sampaikan, atas perhatian dan kesediaannya diucapkan
terimakasih.

Pemohon

( )
 Protokol Pengajuan Etik Penelitian
Hari/Tanggal/Tahun :

(Diisi oleh komisi etik pada saat diterima)

Judul Penelitian :

Peneliti Utama :

Institusi / program Studi :

No Telepon :

Email :

Alamat :

Pembimbing : 1.

2.
Sponsor :

Tanda Tangan Peneliti Utama :

( Nama Jelas )

1. Jelaskan siapa / apa Subyek Penelitian

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2. Jelaskan perkiraan lama waktu pengumpulan :
a. Lama waktu pengumpulan data Setiap Subyek penelitian
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b. Lama waktu pengumpulan data Seluruh Subyek penelitian
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3. Jelaskan pentingnya penelitian dilakukan
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4. Jelaskan tujuan penelitian
a. Tujuan Umum
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b. Tujuan Khusus ( bila ada )
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5. Jelaskan manfaat penelitian
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6. Jelaskan etika penelitian anda :
a. “Respect of Person “pada penelitian anda
b. “Beneficence- non maleficence”
c. “justice” pada penelitian anda

7. Pelanggaran/ permasalahan etik yang dapat anda prediksi

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8. Bila penelitian anda pada manusia langsung, jelaskan alasan melakukannya langsung
pada manusia
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9. Rancangan penelitian anda apa ?
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10. Jelaskan tentang
a. Populasi penelitian anda
b. Sampel
c. Sampling
d. Kriteria sampel
11. Uraikan dengan singkat teknik pengumpulan data dari subyek penelitian
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12. Instrumen penelitian anda apa ?
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13. a. Apa bahaya langsung atau tidak langsung yang mungkin akan terjadi.
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b. Cara mengatasi
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14. Jelaskan situasi / kondisi apa saja yang dialami responden anda yang mengharuskan
anda menghentikan keterlibatan subyek tersebut dari penelitian anda.
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15. Bagaimana cara anda menjaga kerahasiaan data :

 a. Selama penelitian
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b. Setelah penelitian selesai
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16. Inform Consent anda harus berisi :
a. Tujuan Penelitian
b. Jaminan kerahasiaan
c. Metode/cara yang digunakan penelitian
d. Resiko yang mungkin muncul
e. Manfaat penelitian
f. Hak untuk mengundurkan diri
g. Identitas peneliti : Nama, alamat,, telepon, kontak peneliti
17. Apabila terjadi hal yang tidak diinginkan pada subyek penelitian selama dan setelah
penelitian dilakukan, bagaimana cara peneliti mengatasi ?

Banjarmasin, ..................................................
Peneliti Utama

( Nama Lengkap )
FORMULIR TELAAH REVIEWER ETIK PENELITIAN
Nama Penelitian :
Institusi / Program Studi :

No Diterima Revisi Catatan

Pertanyaan
1.*

2.* a

3.

4. a

5.

6.* a.

b.

c.

7.*

8.

9.

10. a.

b.

c.
 d.

11.

12.

13.* a.

b.

14.*

15. * a.

b.

16. * a.

b.

c.

d.

e.

No Diterima Revisi Catatan

Pertanyaan
f.

g.

17.*

( Ditolak apabila 7 kritikal poin (*) tidak dijelaskan pada pertanyaan )

Simpulan / Rekomendasi :
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Banjarmasin, ..........................................
Reviewer

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