‫المملكة العربية السعودية‬

Kingdom Of Saudi Arabia

‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department

Attachment (1)

RESEARCH APPLICATION
FORM
General form

Title of the project:

 

 Incidence of deep venous thrombosis in patients undergoing craniectomy

for brain tumors in Taif, Saudi Arabia: a retrospective study from 2015 to 2020.

1
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department

Instructions:

For your Research Application to be processed in a timely manner, you should make
sure to read these points carefully :

1- Submission letter from Principal investigator through his/her Institute /Department

Director with attached protocol.
2- If the researchers from outside KAASH:
- At least one of investigators should be from KAASH.
- Research unit will coordinate with relevant departments to assign names of
investigators from KAASH .Their names will be send to Principal
investigator.
3- Application form and attachments filled and completed electronically.
4- Signatures scanned or hard copies (investigators,supervisors,Head departments).
5- All sections of the application must be completed. Enter “not applicable” where
appropriate.
Send all required documents to Planning,Training,Researches and Continuous -6
Education Department . or through e-mail : [email protected]
: For any query contact -7
Tel: 00966127310800 – ext: 5577 or email : [email protected]

Contents:
2
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department

1- Cover sheet (Contact information , roles/tasks in the study and Signatures of all investigators).
2- Research Proposal.
3- CV of all investigators.

3
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department

Cover Sheet No:

Submission date: - -
    
Title of the study:
 Incidence of deep venous thrombosis in patients undergoing craniectomy
for brain tumors in Taif, Saudi Arabia: a retrospective study from 2015 to 2020.

Contact Information and Signatures of all investigators:

Name of
principal
Institute/ ID/Work
investigator Position E-mail Signatures*
Department number/Mobile
and other
investigators
Name of
principal
investigator:

Name of Co
1101321295 Afrah.Alhar
investigator 1: Taif Medical
43801475 thi295@gm
Afrah Awad University Student
0505147035 ail.com
Alharthi
Name of Co
1096194574 Ahoodmadk
investigator 2: Najran medical
436301798 ily@hotmai
Ahood Ahmad University Student
0508299773 l.com
Mahjari
Name of Co
investigator 3:

Name of Co
investigator 4:

Name of Co
investigator 5:

Name of Co
investigator 6:
gkorir97@g
GILBERT  KO
mail.com
RIR

4
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department

Roles /tasks of each investigator in the study:

Name of principal
investigator and other Role /task of each investigator Signatures*
investigators
PI name: Supervising and monitoring the study.Choosing
the title, introduction, research question,
objectives, hypothesis, study design, selection of
the variables, settings of the study, data collection
tools, ethical consideration, statistical issues,
timeline, data collection, data management, and
analysis, final report and manuscript
Co investigator 1: Choosing the title, introduction, literature review, research
Afrah Awad Alharthi question, objectives, hypothesis, study design, selection of the
variables, settings of the study, data collection tools, ethical
consideration, statistical issues, timeline, data collection, data
management, and analysis, final report and manuscript.
Co investigator 2: Choosing the title, introduction, literature review, research
Ahood Ahmad Mahjari question, objectives, hypothesis, study design, selection of the
variables, settings of the study, data collection tools, ethical
consideration, statistical issues, timeline, data collection, data
management, and analysis, final report and manuscript.
Co investigator 3: Choosing the title, introduction, literature review, research
question, objectives, hypothesis, study design, selection of the
variables, settings of the study, data collection tools, ethical
consideration, statistical issues, timeline, data collection, data
management, and analysis, final report and manuscript.
Co investigator 4: Choosing the title, introduction, literature review, research
question, objectives, hypothesis, study design, selection of the
variables, settings of the study, data collection tools, ethical
consideration, statistical issues, timeline, data collection, data
management, and analysis, final report and manuscript.
Co investigator 5: Choosing the title, introduction, literature review, research
question, objectives, hypothesis, study design, selection of the
variables, settings of the study, data collection tools, ethical
consideration, statistical issues, timeline, data collection, data
management, and analysis, final report and manuscript.
Co investigator 6: Choosing the title, introduction, literature review, research
GILBERT  KORIR question, objectives, hypothesis, study design, selection of the
variables, settings of the study, data collection tools, ethical
consideration, statistical issues, timeline, data collection, data

5
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department
management, and analysis, final report and manuscript.

* Through their signatures the investigators agree to 1) participate in the study as described in this
application and submitted protocol , 2) Include within the authorship ,of any scientific articles arising
from the research , only those individuals contributing significantly as their names and tasks
mentioned in the submission.

Name and Signature of Academic Supervisor Signature**

(IF APPLICABLE)

** Through his /her signature Academic Supervisor agree that he/she reviewed this proposal and
approve the participation of the concerned personnel in it.

Study Timeframe:

Estimated study commencement date Estimated study end date

Research Proposal
A. Impact analysis
The purpose of this section is to document where the study will be done and describe
how hospital, Faculty resources and study participants will be affected.
A.1 Where will the research be carried out? Is this a multi-site study?

A.2 Is on-site space required?

If yes please give details:

A.3 Please indicate all areas affected by this research and append letters of endorsement
from the appropriate Heads:
Not applicable
Surgery
Ward/Department
Pharmacy
Admission Office
Operation Room
Medical Records

6
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department
Respiratory
Therapy
Outpatients
Clinic(s)
Clinical Nutrition
Diagnostic Imaging
Laboratory
Medicine
ECG/EEG/EMG
Other(Specify)

A.4 Is this project contributing to the Principal Investigator’s or Co-Investigator’s

Master's Degree, PhD Degree or any other Degree? Yes No

*If yes, please provide the name and details of the Institution and supervisor

B. Summary of proposed research:

B.1 Rationale & Background (Please include evidence of recent literature review):

B.2 Objectives:

B.3 Materials & Methods:

● Basic Study Design:

● Study population, study sample:

● data-collecting instruments (Measurements, questionnaires, interviews etc.). Please enclose a

copy of these instruments:

● Data Analysis (How will the results be analyzed? What statistical methods will be used and why
were they chosen?

B.4 Outcome Measures (what will be measured and how?

7
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department
B.5 Will results be acted on in any way? e.g. will subjects with pathologic results that affect or need
treatment be followed up/offered treatment?

C. Ethical consideration
C.1 Informed Consent:
● What information will be given to subjects and how will it be given?

● From Whom and How will informed consent be ensured and obtained?

C.2 Confidentiality

● How and where will the data obtained from the study be stored and secured?

● How will respect for the patients’ rights (preservation of the confidentiality of study subject,
data integrity , result sharing, the possibility to withdraw without negative consequences etc.)
be ensured?

C.3 Has this proposal received ethical approval from any other institution(s)?
If yes, please provide name of institution(s) and a copy of approval document(s).

C.4 Do you have any ethical concerns regarding this proposal?

C.5 How will you report back to the involved departments/units and to the Research Ethics
Committee?

D.1 Budget :
Required Not required

Personnel .…………………..…
Supplies/Equipment ……..……
Services ……………………….
Others …………………………
Total …………………..………
D.2 How are the expenses covered? Describe the funding of the project.

D.3 Which Hospital staff will be involved? Indicate which position/category and the extent.

E. Additional comments and information:

8
 ‫المملكة العربية السعودية‬
Kingdom Of Saudi Arabia
‫وزارة الصحة‬
Ministry Of Health

‫مستشفى الملك عبد العزيز التخصصي بالطائف‬

King Abdul Aziz Specialist Hospital
‫إدارة الشئون األكاديمية والتدريب‬
Academic Affairs and Training Department

F. Enclosures:
● Informed consent
● Protocol ( if any )
● Survey questionnaire ( if any )
● Data sheet

G. Certification
I certify that the information contained herein is true and correct, and that I have received or have
requested approval to conduct this research project from all persons sharing in this research and from
officials of all project sites.

Name and Signature of principal investigator :

:Date