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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE,
KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
“AN EXPERIMENTAL STUDY TO ASSESS THE
EFFECTIVENESS OF FRESH GOOSEBERRY JUICE WITH ELEMENTAL
IRON SUPPLEMENTATION VS ELEMENTAL IRON SUPPLEMENTATION ON
LEVEL OF ANEMIA AMONG ADOLESCENT GIRLS WITHANEMIA IN
SELECTED SCHOOL AT MALUR, KOLAR DISTRICT”
M. Sc Nursing Dissertation Protocol submitted to
Mr. Salic Rahuman . N
M .Sc NURSING 1ST YEAR
2011-2013
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, BANGALORE KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Name of the candidate : Mr. N. Salic Rahuman
Maulr - Hosur Road
Malur -563130, Kolar
Name of the Institution : Manasa College of Nursing
Maulr - Hosur Road
Malur -563130, Kolar
Course of study and subject : 1st Year M.Sc. Nursing in Community Health Nursing.
Date of admission to course : 19-10-2011
Title of the topic : An experimental study to assess the effectiveness of fresh gooseberry juice with elemental iron supplementation Vs elemental iron supplementation on level of anemia among adolescent girls with anemia in selected school at Malur in Kolar district.
6.0 BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“The adolescent girl still remains a young planet that neither gets
Light or water, She remains the flower that could have blossomed
But didn’t”
Adolescence Is The Period When The Individual Can Be Shaped And Molded Into
Great Adults Psychologically. The Sense Of Identity And Crisis Of Intimacy And
Isolation Increase As Adolescent Progress Towards Young Adulthood And Move From
Dependency To The Beginning Of Independence. Metamorphically Adolescents Change
Their Behavior Patterns And Values As well. The Rates Of Change In Attitude, Interest
Are Seen As Parallel To The Rate Of Physical Change In The Growth And Development
Of An Adolescent, The Emotional Disturbance Might Lead Them To React To
Frustration Through Maladjusted Behavior By Children Were More In Schools And
Colleges [Lalitha,1999]
Global database by WHO [2007]on child growth and malnutrition and national
family health survry-2 in India, had suggested that adolescent girls of urban, semi urban
& rural schools in India are found to be anemic & prevalence rate between 61.9 to 88.1
percentage, begin highest among rural girl of higher order as compare to urban poor girls
irrespective of their age menarcheal status. This could be due to difference in dietary
habits, worm infestation, poor hygiene, poor sanitation. anemia prevalence was more
among girls of low weight, height & BMR as compare to those who were heavier, tall
and having higher BMR
India is one of the fastest growing youth populations in the world with an estimate
190 millions adolescent of which 22% are girls. the government of Karnataka directorate
of public health and preventive medicine [2002] conducted a study on prevalence of
anemia among adolescent girls in the urban were anemic. directorate of public health
reports stated that 3.44% of school adolescents are anemic out of which 59% of them are
receive iron & folic tablets.
Anemia is one of the most widespread public health problems, especially in
developing countries like India &has important health &welfare, social & economic
consequences. these include repaired cognitive development, reduced physical work & in
severe cases, increased risk of mortality particularly during the perinatal period. There is
also evidence that anemia may result in reduced growth & increased morbidity. Given
the magnitude of the problem, greater efforts are needed to develop & implement
programs both to prevent & to control anemia. park[1998] suggested that iron deficiency
anemia is a major nutritional problem in India and in many other developing countries
20-40% of natural deaths are due to anemia during pregnancy.
Stoltzfus [2003] consider iron deficiency to be one of most prevalent forms of
malnutrition. yet there has been a lack of consensus about the nature & magnitude of
health consequences of iron deficiency in population. The public health importance of
iron deficiency anemia which was made as part of the global burden of disease [GBD]
2000 project, iron deficiency is consider to contribute to death & disability & also
through its direct contribution to cognitive impairment, decreased work productivity, and
death from severe anemia based on meta-analysis of observational studies, mortality risk
estimates as the decreased risk in mortality for each 1g/dl increase in mean hemoglobin
concentration. on average, globally 50% of the anemia is assumed to be attributable to
iron deficiency. globally iron deficiency ranks number among 26 risk factors included in
the GBD 2000,and accounts for 8,41,000 deaths & 35,057,000 disability adjusted life.
there is an urgent need to develop effective & sustainable intervention to control iron
deficiency anemia.
The bio availability of iron can be enhanced by positive dietary habits & reduce
the intake of inhibitors and enhanced iron absorption through vit-C,vit-A rich fruits &
vegetables. [yegammai & A.swarnalatha,2003]
6.1
In India, the existing prevalence studies were carried out mostly in northern states,
agarwal had documented that the prevalence of anemia was 46% in pre menarcheal girls
as compared to 48% in post menarcheal girls in the urban shams of north east delhi. in
rural India a survey is conducted among 13 to 19 years old girls & found out anemia
prevalence rate of 83% among girls in schools & 93% among girls not in school.
[agarwal,1998]
Iron deficiency anemia is a major nutritional problem of both developed &
developing countries.4.5 billion people of the world’s population are anemic. the
incidence of anemia is highest among women & young children varying between 60% to
70%.[yegammai & swarnalatha,2003]
Dietary iron exists in 2 form heme iron found in hemoglobin, myoglobin & some
enzymes. heme iron found in planet foods but also in some animal food. the absorption
of heme iron is affected only minimally by the composition of food media & gastro
intestinal secretions. but non heme iron absorption is affected by other compounds in
food that inhibits or enhance its absorption, phytate, tamins which are polyphenols in tea
inhibits where as presence of calcium helps to improve absorption.
One of the major problem affecting adolescent girls is anemia, a familiar
nutritional problem to be concentrated more to improve their quality of life. since they
are going to be the future home makers.
NEED FOR STUDY
Anemia is the most form of malnutrition among adolescent today. It is of public
health significance in our country. Adolescent (10-19) constitute >20% of our population
in India & 50% suffer from iron deficiency anemia. Both urban % rural, suffer from
anemia & being more in girls than boys. Poor economical status faulty dietary pattern,
lack of awareness & education, urbanization prevalence malaria, hookworm & other
infestation, repeated bacterial infections also influence the incidence & nature of anemia
among growing children and adolescents.
Iron deficiency anemia reduces the work capacity of individuals and entire
population brings serious economical consequences and it may be obstacle to national
development. Also iron deficiency anemia is one of the leading causes for morbidity. Iron
deficiency has effect on all systems in the human bodies. Long standing severe anemic
may lead to congestive cardiac failure.
The adverse effect of iron deficiency anemia differs according ti the age group
example in case of pregnancy if hemorrhage and shock. So thereby increase the risk of
maternal and infant mortality. In case of school going children the concentration and
intellectual skills are affected.
Numerous morbidity studies among studies children have been carried out by
individual researches mostly in urban areas of India. The incidence of malnutrition
including anemia is 40-70%. Giving health education for prevention of preventable
problems and development of healthful living practices, among students, which is one of
the recommendations of the school Health Committee (Narayana 2001)
The investigator has selected gooseberry to provide vitamin C ( ascorbic acid)
because it is locally available than any other sources and it has value of Vitamin C (750
in 100gm of gosseberry) and ferrous sulphate with 30mg of elemental iron for iron
supplementation.
Also during the review of literature the investigator come across many studies on
synthetic ascorbic acid and iron absorption. Only few studies are a natural ascorbic acid
6.2
iron absorption. This gave to the investigator to study the effort of gooseberry juice on
iron absorption.
REVIEW OF LITERATURE
Studies related to influencing iron absorption
In the year 2000, Zijip conducted a study the effect of tea and other dietary factor on
iron absorption .Because several dietary factors can influence this absorption. He says that
absorption enhanced by ascorbic acid and meat, fish and poultry. Inhibitors are plant
components in vegetable, tea and coffee, calcium. The following recommendations are made to
increase home iron intake,
Increase meal time ascorbic acid intake, fortified food with iron. Recommendations with
respect to tea consumption include, consume tea between meals instead of during the meals,
and simultaneously consume ascorbic acid, acid, fish and poultry.
Fishman, et.al (2000) their work provides a systematic review of vitamin
supplementation trials that reported changes in anemia or iron status. Resume of the study
shows vitamin a can improve hematological indicators and enhance the efficacy of iron
supplementation based data showing it is efficacy in reducing anemia or iron deficiency.
Skeaff, at. al (2001) investigated the efficacy of a dietary regimen involving increased
consumption of iron-rich foods and enhances of iron absorption and decreased consumption of
inhibitors of iron absorption and a low dose iron supplement for increasing iron stores in
young adult women with mild iron deficiency. The investigator concluded that intensive
dietary program has the potential to improve the iron status of women with iron deficiency.
In the year 2001, Cook et.al assessed the effect of ascorbic acid intake on non heme
iron absorption from a complete diet. The facilitating effect of vitamin C on iron absorption
from a complete diet is far less pronounced that from single meals.
Geerlings et. Al (2003) conducted a community based randomized control led
intervention trail to assess the effects of cooking in iron aluminum cooking pots in Malawian
households in an area with high malaria prevalence . They concluded that consumption of food
prepared in iron cooking pots shows a significant rise in hemoglobin after 6 week use. Using
iron cooking pots in developing countries could provide an innovative way to prevent iron
deficiency anemia in malarias areas where regular iron supplementation is problematic.
Ramakrishna, et. Al (2003) conducted a National Health and Nutrition Examination
Survey to examine the relationship between low iron stores and dietary pattern that might
affect iron status among Mexican American woman remained at increased risk for the
prevalence of iron deficiency in maternal woman warrants further investigation.
In the year 2003, Brach et. Al investigated the dose response effect of small amounts of
meat on non heme-iron absorption from a meal presumed to have low iron bioavailability.
Forty five health women with amen age of 24=/-3 years were randomly assigned to 1of 3
groups ,each of which was served (a) basic meal ( rice, tomato sauce , pea puree and a wheat
roll ) and (B) the basic meal with either 2s,30 or 75g pork. The researcher conclude small
amount of meal (> or = 50g) significantly increase non heme iron absorption from a phytate-
rich meal low in vitamin C.
A cross sectional study conducted by Hashizume et. al (2004) of 97 school aged
children living in Kzyl-Orda to investigate anemia related to the sufficiency of dietary iron
intake. The researcher concluded that low bioavailability of dietary iron seems related to
anemia in the region. Although iron fortification or supplementation programees can be useful
for promoting the anemia prevention control programme
Studies related to treatment of anemia
A true experimental study was conducted by Vijayalakshmi et. al (2000) to assess the
bio availability of iron from mug beans and its effect on the nutritional status of adolescent
girls, at Mulaivail, Karur. 150 samples were selected between the age group of 12-18 years.
The anthropometric measurement and serum hemoglobin, iron binding capacity tests were
done for them. The intervention was given for about 40 days. The findings revealed that socio-
economic background indicated that 91.6 percent were from nuclear families, 81.8 percent
were having a family size of 4-6, seventy four percent of girl’s mothers were being illiterate,
and over 75 percent in low income group, before the intervention it the mean value of
hemoglobin was 9.1 gl/dl and after the intervention was 11.3gmldl.There was a significant
seen in the hemoglobin level (p<0.001).
A quasi experimental study was conducted by Nalwade Vijaya et. al (2001)to assess the
nutritional intervention for iron and vitamin A deficiency among 70 adolescent girls, between
the age group of 12-18 years in Parbhani . Anthropometric measures, clinical sings and
symptoms of nutritional deficiency disorders were assessed and 7 hours recall method was
used to assess the food intake of the girls. Iron and vitamin A supplementation were
supplemented to them for 900 days which post test was done. At the end of the study there was
a decrease in the prevalence of anemia (48%) B complex (30%) and vitamin A deficiency
(28.11%) among the experimental group .However in the control group there was significant
differences. There was a significant improvement seen (p<0.001) after the interventions.
Swarnalatha et. al (2001) conducted an experimental study to assess the impact of iron,
vitamin A and vitamin C supplementation on anemic adolescent girls at Sri Narayana higher
secondary school, Ullipudhur.Hundred samples were selected between the age group of 13-15
years. The findings showed that initially over all 35.7 percent adolescent girls was anemic.
Mild and severe anemia in two percent of the subjects. At the end the study overall 26.72
percent adolescent girls were anemic, 9.2 % were mild anemic and severe anemia in 0.98% of
the subjects. There was a significant improvement seen after the intervention (p<0.05).
Brady et. al (2003) conducted a clinical study on iron supplementation and absorption
in the presence and absence of ascorbic acid. The study revealed that fortification with ascorbic
acid increases the bio availability in both presence and absence of inhibiting substances (coco,
caffeine items).ascorbic acid contains micro encapsulation with Lecithin, which birds and
protect the iron particles from the action of inhibiting substances (84%) when human takes the
iron supplements along with ascorbic acid helps to get the higher amount of iron absorption
(p=0.02).
In the year 2005, Juinil was conducted a clinical correlation study on the impact of
vitamins in iron absorption among 200 adolescent girls. Hemoglobin and serum retinol studies
were done for the samples. The study revealed that there is an observed correlation between
serum retinol and hemoglobin levels. The girls with a low serum retinol concentration are more
likely to have iron-deficiency anemia (76.1%),compared to those with normal to high levels of
retinol (24.9%).While vitamin A deficiency has an adverse effect on hemoglobin synthesis,
even a slight increase in vitamin A intake can lead to significant rise in hemoglobin
levels(p<0.001). However, vitamin A is less effective in alleviating severe iron-deficiency
anemia. Without doubt, low levels of iron in the body cannot be relieved by vitamin A
supplementation alone. Additionally, a low ascorbic acid stores in the body causes impairment
in the release of stored iron in the reticuloendothelial cells. Ascrobic acid plays an important
role in modulating ferritin synthesis iron storage.
Studies related to the effectiveness of gooseberry juice and elemental iron
ICMR bulletin (200) the national nutritional anemia prophylaxis programme was
initiated in 1970 iron deficiency anemia in the vulnerable group through daily supplements of
iron-folic acid tablets. The suggested prophylactic doses of iron and folic acid respectively
were 200-240 mg for children per day for 100 days. These tablets were distributed to the high
risk groups by the local health workers.
In the year 200 Sharma Anshu et. al conducted a study on identification of an
appropriate strategy to control anemia in teenaged girls of poor communities of Delhi and
reported that sixty two percent of the respondents in the urban and eighty five percent in the
rural area were anemic. The response of the levels to daily iron/folate supplementation was
better in comparison to once weekly supplementation. The increment in Hemoglobin levels of
respondents due to addition of vitamin C to iron/folate supplementation was more than that
with supplementation of iron/folate alone.
An experimental study was conducted by Februthartanty et. al (2002) to assess the
efficacy of two different iron supplement administered either no a weekly basis or during
menstruation, among post menarcheal female adolescent students in Kupang The study
revealed that weekly supplementation of iron tablets continued for 16 weeks contributed a
higher improvement to hemoglobin concentration compared with supplementing iron tablets
for four consecutive days during menstruation for four menstruation cycles. This suggests that
weekly iron supplementation is preferable.
In 2002, Gopaldas conducted an experiment study among young women 18-23 years of
age in Tara consultancy services, Bangalore. Four small factories were selected in periurban
Bangalore, with a sample of 302 women. The 180 days interventions were supervised at the
workplace. In unit 1 (72 woman), the intervention consisted of idli four times a week plus
information, education, and communication (IEC) related to iron deficiency anemia. Unit 2 (80
woman) received 20 ml of gooseberry juice (containing 40 mg of vitamin C) three times a
week plus IEC once a month. Woman in unit 3 (70 women) , the positive control, received
400mg albendazole once plus ferrous sulfate tablets (60 mg elemental iron ) two times a week.
No IEC was given. Unit 4 (70 women) served as the negative control and received no
intervention. The pre-post impact were in unit 1,2 and 3, the hemoglobin status of the women
improved significantly from 11.10 to 12.30 g/dl, 11.20 to 12.70g/dl, and 11.50 to 13.00 gm/dl,
respectively. In unit 4 there was no change; the values were 10.90g/dl before and after
intervention.
Hinton, Sinclair (2006) conducted a study to determine the effect of iron
supplementation on iron status and endurance capacity. In study twenty iron deficient men and
women were participated. A 30 mg measure of elemental iron as ferrous sulfate daily for 6
weeks was given to the study participants. The results were iron supplementation significantly
improves iron status and endurance capacity in iron deficient male and female subjects
(p<0.05).
An experimental study was conducted by Pereira et.al (2007) to evaluate the efficacy of
weekly iron supplementation in the treatment of iron deficiency anemia. 267 school children,
6-14 years of age group were randomized into two treatment groups. One group (144) received
200 mg iron sulfate alone, With 40 mg of elemental iron, while the other group (123) received
the same iron supplementation dose plus 10,00 IU of vitamin A. Finally, anemia prevalence
was reduced from 48.4% to 17.7% (p<0.001) in the group receiving iron supplementation
alone and 58.1% to 14.3%.(p<0.001).
STATEMENT OF PROBLEM
“AN EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF FRESH
GOOSEBERRY JUICE WITH ELEMENTAL IRON SUPPLEMENTATION VS
6.3
6.4
ELEMENTAL IRON SUPPLEMENTATION ON LEVEL OF ANEMIA AMONG
ADOLESCENT GIRLS WITH ANEMIA IN A SELECTED SCHOOL AT
MALUR ,KOLAR DISTRICT ”
OBJECTIVES OF THE STUDY
1)To asses the pre interventional level of anemia among the adolescent girls in group A and B.2)To asses the post interventional level of anemia among adolescent girls in group A and B.3)To compare the pre interventional and post interventional level of anemia among adolescent girls in group A4)To compare the pre interventional and post interventional level of anemia among adolescent girls in group B5)To compare the pre interventional level of anemia among adolescent girls between group A and B 6)To compare the post interventional level of anemia among adolescent girls between group A and B 7)To associate the mean score level of anemia with selected demographic variables among adolescent girls in group A8)To associate the mean score level of anemia with selected demographic variables among adolescent girls in group B
HYPOTHESIS
H1 : There will be a significant difference between pre interventional and post
interventional level of anemia among adolescent girls in group A
H2 : There will be a significant difference between pre interventional and post interventional level of anemia among adolescent girls in group B
H3 : There will be a significant difference in level of anemia between group A and BH4 : There will be a significant association in the mean score level of anemia with selected demographic variable in group A
H5 : There will be a significant difference between pre interventional and post interventional level of anemia among adolescent girls in group B.
OPERATION DEFINITIONS
6.5
06.6
\
6.7
EFFECTIVENESS : It refers to the decrease in serum hemoglobin level after the administration of fresh gooseberry and elemental iron supplementation for a period of 30 days to the adolescent girls.
ANEMIA : Anemia refers as a reduction of the serum hemoglobin level below the range of 12gm/dl in healthy adolescents.
ADOLESCENT GIRLS : In this present study adolescent girls refer to the belonging to the age group of 13-18 years
FRESH GOOSEBERRY JUICE AND ELEMENTAL IRON : Administration of fresh goose berry juice 20ml and elemental iron 30mg/day after lunch for the period of 4 weeks.
ASSUMPTIONSThe study assumed that,
Most of the adolescent girls are anemic
Vitamin C enhances the iron absorption and thereby increasing the hemoglobin level
Increased iron absorption is reflected with an increase in haemoglobin level
DELIMITATIONS The study will be conduct among adolescent girls who were studying in a selected
school at Malur in Kolar district
The study limited to girls in the age group of 13-18 years
PROJECTED OUTCOME
The present study will help the adolescent girls to enhance their absorption and
thereby increasing the hemoglobin level.
MATERIALS AND METHODS
7.1 SOURCE OF DATA
The data will be collected from the adolescent girls who were studying in
6.8
6.9
7.0
a selected school at Malur in Kolar district
7.1.1 RESEARCH DESIGN
Pretest And Post Test Design Only, Which Is True Experimental Design In Nature Is
Adopted For Conducting The Study.
7.1.2 SETTING
The study will be carried out from adolescent girls in selected school at Malur in Kolar
district
7.1.3 POPULATION
In this study target population comprises of adolescent girls with anemia
METHOD OF DATA COLLECTION
7.2.1 SAMPLING PROCEDURE
According to inclusion and exclusion criteria, the sample will be selected
Simple random sampling technique will be used
7.2.2 SAMPLING SIZE
Sample size will consists of 60 adolescents girls.
30 adolescent girls in group A
30 adolescent girls in group B.
7.2.3 INCLUSION CRITERIA
The study included girls who were
In the age group 13-18 years
7.2
Students present during the study period
Interested to participate in the study
With the hemoglobin levels less than 12gm%
Attained menarche
7.2.4 EXCLUSION CRITERIA
The study excluded girls who were
Psychologically depressed students
With any systemic disease
With history of menorrhagia
Students taking treatment for anemia.
7.2.5 INSTRUMENT INTENDED TO BE USED
SELECTION OF TOOL
Data Collection Instrument Are Extensive Literature,Consultation With Expert And
Opinion Of Faculty Members. Tool Are Prepare on The Basis Of Objectives.
The Tools Use In The Study
Part 1 : Demographic Variable PROFORMA,
Part 2 : Clinical Variable PROFORMA,
Part 3 : Check List For Signs And Symptoms Of Anemia,
Part 4 : Questionnaire To Asses The Knowledge Regarding Anemia Among Adolescent
Girls
Part 5 : Rating Scale on The Level of satisfaction Of Fresh Gooseberry Juice And
Elemental Iron Supplementation.
DEMOGRAPHIC VARIABLE PROFORMA
Demographic Variable PROFORMA Consists Of Age In Years, Religion, Education,
Family Income Per Month In Rupees, Dietary Pattern, Type Of Family, Number Of
Children In The Family.
CLINICAL VARIABLE PROFORMA
Clinical Variable Proforma Consists Of Weight In Kg, Hoight In Cm, Body Mass
Index, Level Of Hemoglobin, Age At Menarche, Frequency Of Menstrual Cycle,
Number Of Days Of Menstruation, Amount Of Menstrual Flow,Receive Of Any
Blood Products,. Habit Of Drinking Coffee
CHECK LIST FOR SIGNS AND SYMPTOMS OF ANEMIA
Check List For Signs And Symptoms Of Anemia Consists Of 20 Items. The Total
Score Is 20. The Scores Were Arbitrarily To
Mild (0-7),
Moderate (8-14),
Severe (15-20).
QUESTIONNAIRE FOR KNOWLEDGE ASSESSMENT ON ANEMIA
Questionnaire For Knowledge Assessment On Anemia Includes The Questionnaire To
Asses The Knowledge Regarding Anemia Adolescent Girls. It Comprises Of 25
Questions With Four Options. Each Question Has One Correct Option.
The Correct Option Score is 1
Wrong is 0
SCORING INTERPRETATION
LEVEL OF KNOWLEDGE RANGE
Adequate Knowledge >50%
Average Knowledge 51-75%
Inadequate Knowledge <50%
LEVEL OF SATISFACTION :
Rating scale on the satisfaction of gooseberry juice and elemental iron supplementation.
SCORE INTERPRETATION
>75% Highly satisfied
51-75% satisfied
<50% dissatisfied
7.2.6 DATA COLLECTION METHOD
Data Collection will be do for a period of One Month.
Researcher collect the data from the Anemic Adolescent Girls.
PILOT STUDY
10 samples will be selected and study will be conducted to find the feasibility and
practicability of the study
7.2.7 DATA ANALYSIS PLAN
The Plan For Data Analysis Was As Follows
Data Analysis Is The Systematic Organization And Synthesis Of Research Data And
Testing Of Research Hypothesis By Using The Obtained Data, Descriptive Statistics
And Chi-Square And Paired 't' And Inferential Use To Analyze The Data Collection.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
-No-
7.4 HAS THE ETHICIAL CLEARANCE BEEN OBTAINED
FROM YOUR INSTITUTIONS?
YES, Ethical clearance will be obtained from the research committee of Manasa College
of Nursing, consent will be taken from concerned authority and permission will be taken
from the study subjects before the collection of data.
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9. SIGNATURE OF THE CANDIDATE
10. REMARKS OF THE GUIDE
11. NAME AND DESIGNATION OF
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT
11.6 SIGNATURE
12 12.1 REMARKS OF THE PRINCIPAL
12.2 SIGNATURE