NHSRC FORM 10-01 REQUEST FOR AMENDMENT/MODIFICATION Please complete the following: NHSRC REF. Number Date of Request (NHSRC will not process requests without this number.) Principal Investigator Name Contact Person (if other than PI) Phone # Email Phone # Email Title of Study 1. Description of proposed changes: (Note: Changes will not be implemented before NHSRC approval. Attach the original document with highlighted changes/modifications) Use attachments and additional pages, as needed. 2. Reason for Amendment/Modification: 3. Changes to Consent Form: Are changes required? No _______ Yes _______ (If Yes, attach new consent form and highlight the changes) _____________________________________________________________________ Signature of Principal Investigator Date NHSRC Office Use only: Approval Approval of Changes /Modifications by NHSRC date:______________________ Approved by: Signature Date Recommended :_______ NHSRC Chairperson or Authorised Not recommended :_______ Signatory Full committee Review_______ Promoting Scientific and Ethical Conduct of Health Research in Malawi Executive Committee: Dr M. Joshua (Chairperson), Dr F. Sinyiza (Vice-Chairperson) Registered with the USA Office for Human Research Protections (OHRP) as an International IRB IRB Number IRB00003905 FWA00005976 Email: research@health.gov.mw/mohdoccentre@gmail.com
