University of South Africa
FORM 1: 2022
AMENDED FOR HRBUS83/2022
ETHICAL CLEARANCE SIMULATION
Research ethics application form for conducting research involving either
primary, or a combination of primary and secondary human participant data.
For research that involves the explicit use of secondary data, please complete
form 2.
Please contact Dr Stander should you require form 2.
TOTAL MARKS: 100
a. The proposed study involves human participants YES NO
X
a.1 Directly through the collection of primary data X
a.2 Both directly and indirectly through the secondary use of data (If X
secondary data is the main data source, please complete Form 2,
Secondary Data Application)
b. Collecting personal or confidential information X
c. UNISA employees, students or data X
d. Potential conflicts of interest (real or perceived) could arise during X
the course of the research
PRIVACY INFORMATION:
The personal information you provide on this form is collected for the primary purpose of
assessing your research ethics application. This personal information will be entered into a
database to assist with administration, correspondence, and statistical analyses. Office
bearers of the Ethics Review Committee as well as the HRBUS83/2022 Team that will
process this application have access to these records. Records will be made available to
authorised third parties should the need arise such as the National Health Research Ethics
Council (NHREC) and Unisa structures such as the Unisa Research Ethics Review
1
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
,Committee (URERC). All records will be retained for as long as necessary to achieve the
purpose for which it was collected.
2
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
,TEAM MEMBER RATING
Student number Surname Contribution out of 45
Use the following scale to rate the contribution of each team member.
5 = Excellent, 4 = Good, 3 = Acceptable, 2 = Marginal, 1 = Unacceptable
How to determine the contribution?
Student number of
team member
Attended team meetings
(online or otherwise)
Was punctual
Was willing to listen to others
Gave the project a high
priority and willingly accepted
responsibilities
Helped to identify and clarify
problems
Was willing to discuss
disagreements and adapt, if
necessary
Helped to make sure that
everyone understood the
solution
Completed assigned tasks as
promised and on time
3
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
, Saw what had to be done
and did it without prompting
or pressure
TOTAL
MAXIMUM
4
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
FORM 1: 2022
AMENDED FOR HRBUS83/2022
ETHICAL CLEARANCE SIMULATION
Research ethics application form for conducting research involving either
primary, or a combination of primary and secondary human participant data.
For research that involves the explicit use of secondary data, please complete
form 2.
Please contact Dr Stander should you require form 2.
TOTAL MARKS: 100
a. The proposed study involves human participants YES NO
X
a.1 Directly through the collection of primary data X
a.2 Both directly and indirectly through the secondary use of data (If X
secondary data is the main data source, please complete Form 2,
Secondary Data Application)
b. Collecting personal or confidential information X
c. UNISA employees, students or data X
d. Potential conflicts of interest (real or perceived) could arise during X
the course of the research
PRIVACY INFORMATION:
The personal information you provide on this form is collected for the primary purpose of
assessing your research ethics application. This personal information will be entered into a
database to assist with administration, correspondence, and statistical analyses. Office
bearers of the Ethics Review Committee as well as the HRBUS83/2022 Team that will
process this application have access to these records. Records will be made available to
authorised third parties should the need arise such as the National Health Research Ethics
Council (NHREC) and Unisa structures such as the Unisa Research Ethics Review
1
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
,Committee (URERC). All records will be retained for as long as necessary to achieve the
purpose for which it was collected.
2
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
,TEAM MEMBER RATING
Student number Surname Contribution out of 45
Use the following scale to rate the contribution of each team member.
5 = Excellent, 4 = Good, 3 = Acceptable, 2 = Marginal, 1 = Unacceptable
How to determine the contribution?
Student number of
team member
Attended team meetings
(online or otherwise)
Was punctual
Was willing to listen to others
Gave the project a high
priority and willingly accepted
responsibilities
Helped to identify and clarify
problems
Was willing to discuss
disagreements and adapt, if
necessary
Helped to make sure that
everyone understood the
solution
Completed assigned tasks as
promised and on time
3
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
, Saw what had to be done
and did it without prompting
or pressure
TOTAL
MAXIMUM
4
2019_ERC_Human Participant Application Form 1, V 3 (SRIPCC 14 /02/19); V2 (Approved by URERC 3 Feb 2017; V1
approved 27 June 2016) _ AMENDED FOR HRBUS83_ETHICAL CLEARANCE SIMULATION
