Proforma for Registration of Subjects for Dissertation s1

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

“ A study to assess effectiveness of structured teaching programme on knowledge and attitude regarding immunization in under five children among postnatal primimothers in selected Govt. District Hospital at Tumkur”

Submitted By, Ms. M. Parvathamma 1st year M.Sc. (NURSING) Obstetric and Gynaecological Nursing Shridevi College of Nursing Tumkur-06 2008-09

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

MS. M. PARVATHAMMA

1ST YEAR M.SC. (N)

1. NAME OF THE CANDIDATE AND SHRIDEVI COLLEGE OF NURSING, ADDRESS LINGAPURA, SIRA ROAD,

TUMKUR-06

2. NAME OF THE INSTITUTION SHRIDEVI COLLEGE OF NURSING

3. COURSE OF STUDY AND SUBJECT 1ST YEAR M.SC. (N)

OBSTETRIC AND GYNAECOLOGICAL NURSING

4. DATE OF ADMISSION TO COURSE 14/06/2008 A STUDY TO ASSESS EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME ON

5. TITLE OF THE STUDY KNOWLEDGE AND ATTITUDE REGARDING

IMMUNIZATION IN UNDERFIVE CHILDREN

AMONG POSTNATAL PRIMIMOTHERS IN

SELECTED GOVT. DISTRICT HOSPITAL AT

TUMKUR

6. BRIEF RESUME OF THE INTENDED WORK

Introduction:

“TODAY CHILDRENS ARE TOMORROW CITIZENS ”

2 Immunization describes the whole process of delivery of vaccine and the immunity it generates in an individual and population. A vaccine is a special form of disease. Causing agent (e.g.: virus or bacteria) that has been developed to protect against that disease. 1

The term “Immunity” relates to the resistance of the body to the deleterious effect of agents (pathogenic) such as bacteria, virus etc. Immunization has played a significant role in the reduction of morbidity and mortality from bacteria and viral infection in many countries.2

The body`s immune system responds to a vaccine by producing substance(such as antibodies and white blood cells ) that recognize and attack the specific bacteria or virus contained in the vaccine. Whenever the person is exposed to the specific bacteria or virus, the body automatically produces these antibodies and other substances. The process these of giving a vaccine is called vaccination. Although use the more general term “Immunization”. Immunization is a act of creating immunity by artificial .(or)inoculation a method of stimulating resistance in the human body to specific diseases using organism bacteria or virus that have been modified or killed.3

There are two types of immunizations: Active and Passive. In Active immunization vaccine are used to stimulate the bodies natural defence mechanisms. Passive immunization is used for people whose immune system does not respond adequately to an infection or for people who acquire and infection before they can vaccinated.3 Immunization is an important aspect of preventive health care globally and will be a topic concern to many new parents .There are different forms immunization, but they all function through stimulation of the immune system in order to enhance resistance to a particular mechanism of infection. Vaccines are available for a range of disease, some of which have severe symptoms (eg. Polio)

3 where others are important for protection against congenital defects. Immunization against rubella (German measles) is a good example of protecting the general population.4

In 1978, Expanded programme on Immunization was started by the Government of India to reduce mortality and morbidity and also to achieve self- sufficiency in the production of vaccines. Communicable diseases are still number one killer ailments of mankind with 16.5 million deaths every year. Measles killed 2 per 100 cases in the developing world and this can be high as 10 per 100 or even more in the areas inhabited by the poorest of the poor having combined misfortune virtually all the children would catch measles. In world every year 5 million children’s are die because of Tuberculosis, Diptheriam Tetanus, Pertussis and Poliomyelitis.5

According to WHO report (1997) there has been 19 percent of under five mortality in the developing world due to diarrhoeal diseases and about 18 percent due to vaccine preventable diseases. The recent study (2006) conducted in India revealed that 71.7% of children were fully immunized, 9.8% were partially immunized and 8.5% had not been immunized. Coverage of each individual vaccine shows that BCG (85.6%), DPT-1(90.3%), DPT-2(88.7%), DPT- 3(80.2%), OPV-1(92.0%), OPV-2(90.3%), OPV-3(82.2%) and measles 73.6% and also they have found that not being aware of the immunization schedule was cited as the main reason (41.2%) and non availability of the immunization service was another reason (45.5%).6

In consideration of the fact that vaccine preventable diseases namely diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis were responsible for considerable morbidity and mortality all over the world, WHO in 1974 introduced a global immunization programme against there diseases known as expanded programme of immunization. This programme was launched in India in 1978 and a steady increase in the immunization level of preschool children.7

4 Initially, the programme was focused on children under 5 years but later children under 2 years were targeted. Eventually in 1985 with a view to energizee and universalize the immunization coverage, EPI programme was redesignated as “Universal Immunization Programme” (UIP) in India and the target age for children was further reduced to infancy. In due course, as the UIP activity expanded and covered the entire country, the immunization coverage in respect of oral polio vaccine increased to more than 90%.7

NEED FOR THE STUDY “Healthy citizens are the Health of the Nation” In our nation majority of people are illiterates and in rural areas with ignorance, innocence and lack of knowledge about immunization they may be easily prone to get diseases. Routine immunization of children have been

5 extremely successful in the prevention of selected diseases. The ultimate challenge is making sure children receive immunization. The health policy 2000 goals including the immunization for the nine childhood diseases of 90% of 2 Year old children in the United States by the year 2000.8

Immunization rates have improved since 1989, largely because of efforts of the health organizations to educate health care providers, parents and Government. In 1973, 71% of civilian children under age 2 years were up to date on diphtheria, tetanustoxoid, pertussis (DTP), polio and measles – mumps – rubella (MMR) vaccines. Only 60% had receive haemophilus influenza and 16% received hepatitis – B vaccines.8 In October 1985, Universal Immunization Programme was started with the objective of the achieving 85% coverage of immunization to children and also to reduce the incidence of polio to 0.05 level. In practice, no country even industrialized world, has even achieved 100% immunization in children. It is however generally agreed that when immunization coverage reaches a figure of 80% or more, then disease transmission patterns or so severely disrupted. At the beginning of the programme in 1985 – 86, vaccine coverage ranged between 29% for BCG and 41% for DPT.5

A series of immunizations focusing and the most common and the most potentially damaging childhood illness is offered to all children in the UK from about 8 weeks of age. Since women may ask for advice about immunization during their postnatal care. It is important for midwives to increase their own knowledge of its benefits and limitations, recommended practice and contraindications for certain individuals. Women can be referred to their health visitor for detail advice but it will be useful for midwives to discuss current immunization schedule and policies with local health visitors regularly to up date knowledge of the current evidence on the benefits and risks.4

6 To educate the postnatal regarding communicable diseases existing in the developing countries to make postnatal mothers children’s to vaccinate against the six communicable diseases i.e. Tuberculosis, Diptheria, Pertussis, Tetanus, Poliomyelitis and Measles. Educate the postnatal mothers that this immunization schedule against there six deadly communicable diseases should be completed before the completion of one year of the child.

Health teaching an important means bringing about health behavior among mothers. It emphasizes a significant attitude towards health which enables mother to take the vaccines to their childrens.9

Since investigator working in a hospital found postnatal mothers are not immunize to their children’s especially rural peoples because they have lack of knowledge about the immunization, malnutrition and lack of immunity to the children’s their easily prone to get the diseases.

So the researcher thought of taking the task of assessing the knowledge of mothers and helping them improving their knowledge, awareness regarding immunization in order to reduce the infant morbidity and mortality rates.

6.2 Review of literature:

“Nursing personnel efficiency developed only by updating knowledge and skills”

7 Review of literature provides basis for future investigations, justifies the need for replication, throws light up on feasibility of the study and indicates constraints of data collection and help to relate finding of one another.

The purpose of it is study in to obtain knowledge and in depth of information about the study.

1. Prymula R, et al. (2008) Conducted study on clinical experience with DTPw-HBV / Hib combination vaccines. In this study the combined Diphtheria-tetanus whole cell pertussis (DTPw) vaccine. Larger DTPw based combination vaccines facilitate high coverage and protection against other childhood pathogens such as Hepatitis B & Heamophilus Influenza (Hib) vaccines have been available since the mid 1990’s .Demonstrating excellent immunogenicity in various schedules. The study conclusions are new antigen source will ensure the continued supply of DTPw based combination vaccines for vital global mass vaccination.10

2. Imbert P, et al. (2008) conducted study on immunization for children traveling to the tropics neglected vaccines. Each year hundreds to thousands of children travel to developing countries where they are exposed to infectious agents that can be prevented by vaccination. The purpose of this study is to understand and need of vaccination and improve information and access to vaccines that are all too often neglected in child travellers. In the vaccination schedule three vaccinations can be considered as neglected. 1. Hepatitis B vaccine that has allow coverage level due to strong reluctance to its use despite the fact that the virus is wide spread in tropical area. 2. Pneumococcal vaccine that should be administred to all infants less than 2 years of age, especially for travel to areas where pneumonia and meningitis are frequent. 3. BCG vaccine is greater risk of neglected child because its use has been downgraded from general requirement to a recommendation only for children.11

8 3. Hamlin J, et al. (2008) conducted study on update on universal child immunization. The purpose of their study is providing an update of findings and recommendations regarding immunization. The findings study is the advisory committee on immunization practice recommends immunization with quadrivalent meningococcal conjugate vaccine for all previously unvaccinated children. The advisory committee on immunization practices the use of the combination measles mumps-rubella-varicella vaccine over separate measles-mumps rubella and varicella administration. Because of anotable recall of haemophillus influenza type B vaccines practices recommends that paediatric conserves available haemophillus influenza type B vaccines administration of the booster dose of the vaccine in healthy children.12

4. Rosenthal SL, et al. (2008) Conducted study to examine the relationship of demographic, parenting, vaccine, attitudes with the acceptance of vaccination in the next 12 months. The subjects of sample was mothers are 153 comple a questionnaire the study results are 18% had not receive the vaccine although it had been offered 34% had not been offered the vaccine and 22% had been offered the vaccine 26% had started vaccination or completed the series.13

5. Samules Rc, et al. (2008) conducted study on immunizations in children with special health care needs in a medical home model of care. Study objectives are assess whether a model of care with augmented services within an existing medical home could improve immunization rates for Children with Special Health Care Needs (CSHCN) and to evaluate the influence of family and practice on childrens immunization. The research design prospective survey the study results the immunization rates of children with special health care needs in the practices before the intervention was 83.4%for DTP, Polio, MMR and 80% of HIB and Hep B were added. The study conclusions in these practices immunizations to groups of patients among these CSHCN were more likely to be delayed with immunization including those with late onset disorder and those with high family income.14

9 6. Nolan T, et al. (2007) conducted study on DTP-HBV-OPV vaccine for primary vaccination of infants. The study aims combined vaccines have an increasingly important role to play in delivery antigens and reactogenecity of combined DTP-HBV-OPV vaccine Diphtheria, Tetanus, a Cellular Pertussis Hepatitis B in activated poliovirus administred for the primary vaccination of infants. The study results was one month after the primary course at least 98.9% of subjects achieved sero-protective antibody concentration / titres against Diphtheria, Tetanus, Hepatitis B and polio. More than 97% had a vaccine response to pertussis antigens the study conclusions the DTP-HBV-OPV vaccine is a new combination of vaccine.15

7. Lamiya samad, et al. (2006) conducted study on immunization. The objectives of the study is to compare the demographic, social, maternal and infant related factors associated with partial immunization and no immunization in the first one year life of infants. The research design is used for this study is cohort study sample was taken from the who are admitted in electoral wards in England, Wales, Scotland, Northern Ireland study result was 3.3% of infants were partially immunized and 1.1% were un immunized. The conclusion of this study postnatal mothers who having infants unimmunized differ in terms of age and education from those of partially immunized infants.16

8. Bosompra K, et al. (2004) Revealed study on attitudes, perceived norms and intentions a need assessment of the immunization intensions of rural mothers in Vermont. The purpose of study the examined the association of attitudes, perceived norms and intention to obtain information immunization among community rural mothers. Methods are used for random digit dialinig selected 1,239 households in 2 rural Vermont countries telephone interventions were conducted with 799 mothers resulting in a response rate 65% findings analysis revealed 2 dimensions underlying attitude, perceived benefits and both normative indices were significant predictors of immunization intension. Conclusion of the study were interventions programme targeting rural mothers should emphasize the benefits and perceived side effects of immunization. The programme should publicize that most mothers believe that the advantages and disadvantages of immunization.17

10 9. Manjunath U, et al. (2003) a cross sectional study on immunization conducted a total number of 166 postnatal mothers was interviewed using a pre-tested interview schedule/questionnaire on Knowledge, Attitudes, Perceptions and expectations (KAPE). The results showed that among the 12-24 month old children 50% fully, 31.3% partially & 18.7% not at all immunized. High levels of initial vaccination rates and low levels of

OPV3 DTP3 (62.7%) and measles (51.8%) vaccines indicate that completing vaccination schedule needs attention. Majority of the postnatal mothers expressed favorable attitudes and satisfaction regarding the programme. Many were not ware of the importance of vaccination, information about importance of completing schedule and knowledge about vaccine preventable diseases other than poliomyelitis was very limited.18

10. Nahum E, et al. (1994) conducted research on the immune response to Booster vaccination against diphtheria toxin at age 18-21 weeks. The purpose of this study was to evaluate the immunity against the diphtheria toxin & to assess the immune response booster vaccination of diphtheria. The antibody levels measured in 200 volunters dosage of 21f (flocculation units) was given and the immune response measured. The findings that prior to the booster vaccination 174 (87%) of the study group an antibody level ≥or 0.1IU/ml 16 (8%) had an antibody level of >0.6 IU/ml and 10(5%) had an antibody level <0.05 IU/ml. At the 10th day after the booster vaccination 185 (99%) acquired antibody level >0.1 IU/ml, 28th day all the vaccines had antibody level above 0.1 IU/ml. when comparing booster vaccination no significant difference was found between the prior to the vaccination. Study concludes that antibody levels >0.1 IU/ml are protective and booster vaccination at dosage of 2Lf raises the antibody levels to protective levels in all the vaccines.19

11. Wadsworth L, (1999) Conducted research on polio immunization dealing with new recommendations and helping parents understand the changes. In this study polio immunization have recently undergone some major changes and use of the live oral poliovirus vaccine has occurred and an increasing preference is being shown for the killed injectable poliovirus vaccine for at least the first two doses. The study purpose to

11 review the history of polio and polio vaccines, compare the risks, benefits and indications of the 2 available vaccines and diseases the rationale for changes in recommendations.20

6.3 Objectives of the study:

 To assess the knowledge and attitude regarding immunization in under five children among postnatal primimothers before structured teaching programme.  To assess the knowledge and attitude regarding immunization in under five children among postnatal primimothers after structured teaching programme.  To evaluate the effectiveness of structured teaching programme by comparing the pre and post test knowledge scores.  To find out the association between the demographic variables and postnatal primimothers knowledge and attitude regarding immunization in underfive children.

6.4 Operational definitions:

Following definitions are used by investigator.

1. Assessment: It is refers to the organized and systematic process of collecting information. 2. Effectiveness: In this study it refers to the power of the bringing changes in the knowledge and attitude regarding immunization among postnatal primimothers after the administration of structured teaching programme. 3. Structured teaching programme: In this study it is educate system that can guide, teach, promote understanding, and improve knowledge and attitude regarding immunization among postnatal primimothers. 4. Knowledge: In this study it is defined as a level of awareness among selected subjects and it is elicited by structured knowledge questionnaires. 5. Attitude: In this study it is refers to the expression or belief of the postnatal primimothers regarding immunization in underfive children.

12 6. Immunization: It is refers to the act of creating immunity by artificial against infectious diseases. 7. Postnatal primimothers: It is refers to the mothers who gave first birth to a new born still in the period of puerperium.

6.5 Research Hypothesis:

The study is based upon following hypothesis.

H1: The mean post test knowledge score will be significantly higher than mean pre test knowledge score.

H2: There will be a significant association between the knowledge score and selected demographic variables.

6.6 Assumptions:

 Postnatal primimothers may not have adequate knowledge on immunization in under five children.  Structured teaching programme may facilitate better learning it will be useful in improving knowledge and attitude regarding immunization in underfive children among postnatal primimothers.  This study may control the complications and improve knowledge and attitude regarding immunization in underfive children among postnatal primimothers. 6.7 Delimitations:

o This study will be limited to postnatal primimothers at selected Govt. district Hospital in Tumkur. o This study is limited postnatal primimothers who were available on the day of data collection. o Sample size is limited to 100 postnatal primimothers.

13 o The study will be limited to mothers who know Kannada and English.

6.8 Pilot study:

Pilot study will be conducted with 6 samples. The purpose of pilot study is to find out the feasibility of conducting study and design on plan of statistical analysis.

6.9 Variables:

Research variables are the concepts at various levels of abstraction that are entered manipulated and collected in a study.

1. Dependent variable – Knowledge level of postnatal primimothers regarding under five children immunization. 2. Independent variable – Structured teaching programme 3. Extraneous variable – Age, Sex, Educational status etc

7. MATERIAL AND METHODS

The study is designed to determine the effectiveness of structured teaching program on knowledge and attitude regarding immunization in underfive children among postnatal primimothers in selected Govt. district Hospital in Tumkur.

7.1 Sources of Data:

14 Data will be collected from postnatal primimothers in selected Government District hospital, Tumkur.

7.1.1 Research design: Pre-Experimental design one group- pre test Post test 7.1.2 Research approach: The Pre-Experimental one group pre test and post test design will be choosen for the study to assess the effectiveness of knowledge and attitude regarding immunization in under five children among postnatal primimothers.

7.1.3 Setting of the study: This study will be conducted in selected Govt. district Hospital in Tumkur- Karnataka.

7.1.4 Population: In this present study the population was the postnatal primimothers admitted in postnatal ward in selected Hospitals, Tumkur.

7.2. Method of data collection:

Sampling procedure A “Questionnaire” schedule will be used for data collection. The data collection procedure will be carried out for a period of 3 months. The study will be conducted after attaining permission from concerned authorities.

15 At first a good rapport will be established with the samples. The purpose of the study will be explained to them so as to get the co-operation from them for procedure for data collection. The investigator will collect the data from postnatal primimothers by using structured knowledge questionnaire and structured teaching program on knowledge and attitude regarding immunization in under five children. The structured questionnaire schedule consists of two parts. Part 1 and Part 2 Part1: Items on demographic variables like age, sex, educational qualification Part 2: Knowledge and attitude items on immunization

7.2.1. Sampling technique: Non probability convenaient sampling technique will be used for selection of the samples. 7.2.2. Sample size: The sample of the study consists of 60 postnatal primimothers in selected settings. CRITERIA FOR SAMPLE SELECTION 7.2.3. Inclusion criteria: 1. Who are postnatal primimothers 2. Mothers who are willing to participate in the study 3. Who can understand the Kannada and English language 7.2.4. Exclusion criteria: 1. Postnatal primimothers who are not willing to participate in study. 2. Mothers who are not available during the study.

7.2.5. Tool for data collection:  Demographic profile.  A structured questionnaire regarding under five children immunization.

7.2.6. Data analysis method: The data analysis through descriptive and inferential statistics.

16 Descriptive statistics: Mean, Standard deviation range and mean score of subjects will be used to quantify the level of knowledge before and after structure teaching programme. Inferential statistic:  Paired t-test will be used to examine the effectiveness of structure teaching programme by comparing the pre and post test score.  Chi-square test will be worked out to determine the association of socio demographic focuses of postnatal primimothers with pre test knowledge. 7.2.7. Time and Duration: Time and Duration of study will be as per research committee.

7.3. Does the study require any investigation or intervention to be conducted on patients or other Humans or Animals? If so please describe briefly.

Yes, the planned teaching programme will be administered to postnatal primimothers regarding knowledge and attitude on immunization.

7.4. Has ethical clearance been obtained from your institution in case of 7.3?

Yes, the pilot study and main study will be conducted after the approval of research committee. Permission will be obtained from the concerned authorities of the hospital and samples. The purpose and after details of the study will be explained to the study subjects and assurance will be given regarding confidentiality of the data collected. 8. List of References

1. Immunization. (online) 2007 Nov; Available from :URL: http://www.unicef.org/immunization/index.html. 2. M.S.Jessie M.Chellappa. Pediatric Nursing, First edition repriented. Gajanana Book Publisher, 2000, P:42.

17 3. Introduction : Immunization : The Merck Manual Medical Library : The Merck Manual of Medical Information. Home edition (online) July 2008; Available from :URL: http://www.merck.com/mmhe/sec17/ch189/ch189a.html. 4. Myles. Text book of midwives. 14th edition. Churchill living stone. (2004) : 946 – 947. 5. Park.K. Essentials of Community Health Nursing, 19th edition. Jalalpur. Banarsidas Bhanot Publishers; 2006,: 341 – 343. 6. Anita Khokhar. Immunization status in urban community. Indian journal of preventive and social medicine. 2005 December; 36(3&4) : 82 – 86. 7. GM DHAAR I ROBBANI. Foundations of community medicine. First edition. Elsevier India Private limited. P:969. 8. Stanhope, Lancaster. Community Health Nursing; Fourth edition, Mosby Dedicated to publishing 1995: 532. 9. Shaw. Implementing conceptual frame work. Journal of Nursing administration, August 1973, Pp : 8 – 11. 10. Prymula R, Plisek S. Clinical experience with DTPw-HBV and DTPw-HBV/ Hib combination vaccines. Expert opinion on biological therapy 2008 Apr; 8(4); 503-13. Available from: URL: http://www.pubmed.com 11. Imbert P, Guerin N, Sorge F. Immunization for childrens travelling to the tropics: Neglected vaccine: Medicine tropicale 2008 June; 68 (3): 231-5. Available from: URL: http://www.pubmed.com 12. Hamlin J, Senthilnathan S, Bernstein H. Update on universal childhood immunization; Current opinion in pediatrics 2008 Aug; 20 (4): 483-9. Available from: URL: http://www.pubmed.com 13. Rosenthal SL, Rupp R, Zimet GD, Mezea HM, Loza M, Short MB, et al. Uptake of HPV vaccine: Demographics, sexual history and values, parenting style and vaccines attitude. Journal of adolescent health 2008 Sep; 43 (3): 239-45. Available from: URL: http://www.pubmed.com 14. Samuel RC, Lio J, Sofis LA, Palfrey JS. Immunization in children with special health care needs in medical home model of care. Maternal and child health

18 journal 2008 May; 12 (3): 357-62. Available from: URL: http://www.pubmed.com 15. Nolan T, Lambert S, Roberton D, Marshall H, Richmond P, Streeton C. DTPa- HBV-IPV vaccine for primary vaccination of infants. Journal of paediatric and child health 2007 Sep; 43 (9): 587-92. Available from: URL: http://www.pubmed.com 16. Lamiya Samad, A Rose Mary Tate, Carol Dezateux, Neville Butler, Catherine Peckham, Helen Bedford. Differences in risk factors for partial and no immunization in the first year of life: Prospective cohort study. BMJ: Medical expertise at your finger tips 2006 June; 332: 1312-1313. Available from: URL: http://www.bmj.com/cgi/eletters/332/7553/1312. 17. Bosompar K, Ashikaga T, Ruby A. Attitudes perceived norms and intension in its needs assessment study of the influenza immunization intensions. Journal of rural health 2004 spring; 20 (2): 125-30. Available from: URL: http://www.pubmed.com 18. Manjunath U, Pareek RP. Maternal knowledge and Perception about the routine immunization programme: A study in a semi-urban area in Rajasthan. Indian journal of medical sciences 2003 Apr; 57(4): 158-63. Available from: URL: http://www.indianjmedsci.org/article.asp?issn=0019- 5359;year=2003ivolume=57;issue=4epage=163;aulast=may. 19. Nahum E, Lerman Y, Cohen D, Salpon R, Danon YL. The immune response to booster vaccination against diphtheria toxin at age 18-21 weeks. Israel journal of medical sciences 1994 Aug; 30 (8): 600-3. Available from: URL: http://www.pubmed.com 20. Wadsworth L. Polio immunization; Dealing with new recommendations and helping parents understand the changes. Journal of pediatric health care 1999 Nov-Dec; 13 (6pt2):S21-30. Available from: URL: http://www.pubmed.com.

19 9. Signature of the candidate

10. Remarks of the guide

11. Name and designation of (in block letters)

20 11.1. Guide

11.2. Signature

11.3. Co-guide (if any)

11.4. Signature

11.5. Head of the Department

11.6. Signature

12. 12.1. Remarks of the chairman and principal

12.2. Signature