2. for Collection of Survey, a Copy of UTAR SERC Approval Letter Needs to Be Attached

UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATION FOR FIELD TRIP
Form Number : FM-IPSR-PSU-027 / Rev No: 1 / Effective Date: 05/12/2016 / Page No: :1 of 2

Note:

1. This form is only for the application for field trips and not for research attachment

2. For collection of survey, a copy of UTAR SERC approval letter needs to be attached

3. Copy of this from, Field Trip letter of Undertaking & Indemnity and UTAR SERC approval letter needs to be given to IPSR after approval by Deputy Dean (R&D and Postgraduate Programmes).

PART A: CANDIDATE DETAILS

Name of Candidate: / Student ID:
Faculty: / Programme:
Research Project Title/
Research Title:
Date: / Signature:

PART B: DESTINATION, PURPOSE AND DURATION OF TRIP

Duration / Destination / Purpose

PART C: SUPPORTED BY SUPERVISORS

Main Supervisor: / Co-Supervisor
Signature: / Signature:
Date: / Date:

PART D: APPROVAL

Date application received:
Head of Programme / Deputy Dean (R&D and Postgraduate Programmes)
Recommended
Not Recommended / Approved
Not Approved
Signature: / Signature:
Date: / Date :

Date:

Deputy Dean (R&D and Postgraduate Programmes)

UniversitiTunku Abdul Rahman

Dear Sir/ Madam

FIELD TRIP UNDERTAKING AND INDEMNITY

I,______NRIC No ______Student ID No ______

(to state student’s name )

am pursuingProgramme <hereinafter referred to as “I”> refer to the Field Trip form

I hereby declare and confirm that the University shall not be held responsible in the event of any misfortune or accidents and/or personal injuries whether fatal or otherwise involving me.

I shall undertake full responsibility of all the consequences should any other person or body suffer such accidents and/or personal injuries and/or damage to property as a result of my negligent act or omission during the course of Field Trip.

I shall indemnify and keep indemnified the University against any liability, demand, claim, loss or lawsuit in respect of personal injuries to me and/or to anybody and/or property damage arising out of or caused by my negligent act or omission during the course of Field Trip.

I hereby acknowledge and confirm that I have been cautioned to obtain additional insurance coverage for the current Group Personal Accident (for students) Insurance and to obtain the necessary insurance coverage for Medical, Hospitalization and Surgical and Personal Liability Insurance coverage for any accidents or personal injuries or perils or losses or damage caused to persons or body or property during the period of the Field Trip.

I further declare that I shall obtain, maintain and keep these insurance polices valid throughout the period of the Field Trip.

I shall undertake to uphold the good name of the University and abide by the code of conduct of the University and any other relevant rules and regulations at all times during the course of my Field Trip. I shall not hold the University responsible for my misconduct or wrong doing at all times during the course of my Field Trip.

Yours sincerely

…………………………..

Student’s Signature

Name: