Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

| |Name of the Candidate and Address | |

| | |Ms. AMANPREET KAUR |

|1. | |I YEAR M.SC (NURSING) |

| |Name of the Institute |NOOR COLLEGE OF NURSING, |

| | |NO:5 NOOR BUILDING, RMV 2nd STAGE, |

|2. | |BHOOPSANDRA MAIN ROAD, BANGALORE-94 |

| |Course of Study and Subject |M.S.C. NURSING, 1st YEAR, |

| | |PEDIATRIC NURSING |

|3. | | |

| |Date of Admission |01.10.2011 |

| | | |

|4. | | |

| |Title of the Topic | |

| | |A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE|

|5. | |REGARDING TOILET TRAINING AMONG MOTHERS OF TODDLERS IN SELECTED PAEDIATRIC WARD, |

| | |BANGALORE. |

6. INTRODUCTION

“Children are the wealth of tomorrow; Take care of them if you wish to Have a strong India, Ever ready to meet various challenges”

…P.NEHRU

A toddler is a young child usually defined as being the ages of one and three. Registered nurse, mid wife and author, Robin Barker states anytime from eight months your baby will begin to realize, he is a separate person from you. He will find it exciting to be able to move away from you but scary when you move away from him.1

The toddler years are a time of great cognitive, emotional and social development. Toddler development refers to the changes that occur in between 1 and 3 years of age. Change may occur as a result of genetic process known as maturation, or may be due to environmental factors and learning. Usually it involves as interaction between two.2

Toddler developments can be broken into number of interrelated areas. There is reasonable consensus about what these include; physical: refers to growth or an increase in size. Gross motor: refers to the control of large muscle, which enable walking, running, jumping and climbing. Fine motor: refers to the ability of controlling small muscle, enabling the toddler to feed themselves, drawed listen (interpret). Speech is the ability to understand and learn language and use it to communicate effectively. Social: refers to the ability to interact with the world through playing with others, taking turns and fantasy play.3

Toilet training can be considered a progressive process that consists of several stages for which the child must acquire both physical and cognitive self control. It includes discussing, undressing, going, wiping, dressing, flushing and hand washing. It’s an individualized task for each child. It should begin and be completed according to the child’s ability to accomplish it, not according to a set schedule.4

Children learn to care for themselves initially by attempting to imitate the action of their parents and siblings. Achieving control of the bodily functions of defecation and urination is one of the major tasks of the early childhood. The control of bladder and bowel functions involves a complex integration of neuromuscular pathways at the peripheral and central levels. The 50% of the girls and boys are toilet trained at 35 and 39 month respectively.5

There are some habit problems like enuresis and encopresis and some personality problems like shyness, timidity, fear, anger, conflict due to rejected or isolated, jealousy and rivalry towards younger child in the family who have already achieved bladder control, resentment and tension for disturbed bladder control seen due to improper toilet training. 6

World wide, the incidence of behavioral problem on toilet training like Enuresis and Encopresis (with some disease condition) is 15% and 12.6%. The incidence of female child is 60% and in male child 90%.7

Toilet training or potty training is the process of training a young child to use the toilet for urination and defecation. Training may start with a small bowel shaped device (often known as potty). Cultural factors play a large part in what age is seemed appropriate with the expectation for being potty trained ranging from 12 months for some tribes in Africa to 36 months in the modern United States. Most children can control their bowel before their bladder, boys typically start and finish later than girls, and it usually takes longer to learn to stay dry throughout the night.8

Learning to use toilet is a best for toddlers and it can be difficult for some. Some children just seem to train themselves when they are ready, but many need some help from their parents.9 Parents or care giver play a key role in normal behavioral pattern on toilet training. Parents see toilet training as an important milestone for their children and often become very concerned f it doesn’t all go smoothly. For toddlers it is something new to learn. The way in which the parents on care giver approach the process of toilet training are more important than the actual procedure it self. Their relaxed and positive attitude and behavior can influence the way child feel about themselves and others. The correct knowledge and awareness among parents or caregiver is very essential for the success of the child. Sometimes they may have either inadequate or inappropriate knowledge regarding initiation, readiness process and hazards of toilet training. For the total success in each child parents should be aware of proper guidelines. To avoid hazards and to learn normal behavioral pattern, at primary level health professionals especially nurses can provide the perspective needed to help children, parent and care givers, so as to build healthier life and personality. 10

Most of their children are not ready to learn too control their poo and wee (bowels and bladder) until they are at least two years old and some not until they are three. Often boys are later than girls. Control over poo may happen before or after control over wee.It is best not to start toilet training at a time when your child is adjusting to their changes e.g.: when there is a new child in the family or he is starting child care.11

6.1. NEED FOR THE STUDY

”We make a living by what we get. We make a life what we give” - Winston Churchil.

Today’s children are tomorrow’s better citizens. Children will learn new tasks or skills in this age. They will learn new tasks in small steps and each step should be praised. Toilet training is very important tasks to learn for toddlers.12

Most people advise that toilet training is a mutual task, requiring co-operation, agreement and understanding between the child and the mother, and the best potty training techniques emphasize consistence and positive reinforcement. Over punishment making it fun for the child. There are articles suggesting that it is easier toilet train a child when he/ she is at least 18 months of old. This time frame is much easier to use because of the child wanting to please his or her parents.13

Until the mid 1990’s, the vast majority of babies finished toilet training by 2 years and achieved night time dryness by 3 years. Since then the age for toilet training has increased dramatically. The US Department of Labor Children’s Bureau put out a series of publications called infant care. Starting in 1914, and recommended toilet training to be started in the first year until the 1951 edition.14

In 1914 parents were advised to start toilet training by the third month with the utmost gentleness. In 1938, parents were advised to start bowel training “as early as in the 6th month”.By 1951, fears of psychological ramification of early training. Surfaced and parents were advised to wait “between one and a half to two year, to commence training” In 2002 the average age that parents recognized their child “showing an interest in using the potty, was 24 to 25 months and day time dryness was achieved on average at almost three years of age.15

Parents are advised to be prepared to wait until your child is ready. Most toilet training problems can be avoided if you don’t start too early. Teach the child the words needed for toilet training such as wet, dry, wee, poo its coming .Choose the words that you are comfortable.16

A study was conducted with thirty nine children between 29 and 36 months of age, were randomized to wetting alarm diaper training (WAD-T:n=20) or timed potty training ( Tp-Tn=19) in Scotland. Toilet behavior was observed by parents and independent observers, before at the end, and after to weeks of training. Late evaluation the WAD-T group did significantly better than the TP-T group at the end of the training (p-.041) at 14 days p=0.27 independent bladder control was achieved in 88.9% of the WAD-T group. The WAD- T method is a structured child friendly, highly effective option for TT young healthy children.17

A study was conducted in Maharashtra among 200 children between the age group of 3 to 4 years to identify the prevalence of enuresis. The study found out that Enuresis is manifested as the repetitive and inappropriate passage of urine. The voiding may be voluntary or involuntary. A minimum chronological age of 3 years and minimum mental age of 4 are regarded. There is sharply decreasing prevalence up to age 4 and gradually declines there after 82% of 2 years old, 49% of 3 years old, 20% of 4 years old, 7% of 5 years old, 3% of 10 years old and 11% of 19 years old are enumerate. Most children are toilet trained by age of 30 months, although 2% to 10% of children are not toilet trained by age of 4 years. Problems of toilet training have become a common behavioral concern for parents of school going children. 18

A study was conducted in Chennai among 100 children between the age of 3 to 6 years to identify the appropriate age for bowel control. The study revealed that bowel control is estimated to be more than 95% of children by fourth birthday & 99% of children by fifty birthday frequently decrease to virtual absence by age sixteen. At age four the functional encopresis at all ages is 3 – 4 times as common in boys as in girls by age 7 to 8, frequency is 2.3% in boys and a 7% in girls by age 10 – 12, once in a month soiling occurs in 1.3% of boys and in 0.3% in girls.19

The nurse plays an important role in educating mothers of toddlers about toilet training. Education of mothers is the process of assistance to learn and incorporate the toilet training in everyday life. Providing sincere advice regarding methods and advantages of toilet training will provide normal development positively.

This area of study has been selected because even today the mothers are not aware of the importance of toilet training and consequently leads to behavioural disorders.. Hence, the need was felt to identify the learning needs of mothers and educate them regarding toilet training by introducing structured teaching programme and promoting the psychobehavioural health of toddler children which inturn reduces the behavioural disorders among toddler children.

6.2. REVIEW OF LITERATURE

Researchers almost never conduct a study in an intellectual vacuum their studies are undertaken within the context of an existing knowledge base. Al literature review helps to lay the foundation for the study, and also inspire new research ideas.

Review of literature provides the basis for future investigations and indicates constraints data collection. According to Polit and Hungler (1999) literature are critical, summaries of what is known about a particular topic with background of understanding what has been already learned a topic and specify accumulation of knowledge and illuminate about the significant of the new study.20

The investigator organised the review under the following headings:

SECTION 1: LITERATURE RELATED TO TOILET TRAINING

SECTION 2: LITERATURE RELATED TO TOILET TRAINING PROBLEMS

SECTION 3: LITERATURE RELATED TO TOILET TRAINING METHODS

1. STUDIES RELATED TO TOILET TRAINING

A prospective study was conducted to investigate the association between age at initiation of toilet training and development of daytime bladder control. The study is based on more than 8000 children, aged 2.5 to 3 years, from a UK birth cohort- The Avon Longitudinal Study of Parents and Children. Using multinomial logistic regression, the analysis examined the association between age at initiation of toilet training and 4 previously established trajectory groups representing different patterns of development of daytime bladder control (described as "normative development," "delayed acquisition," "persistent daytime wetting," and "relapse"). It was concluded that there is evidence that initiating toilet training after 24 months is associated with problems attaining and maintaining bladder control.21

A prospective study was conducted in Philadelphia on Relationship between age at initiation of toilet training and duration of training in order to investigate the relationship between age at initiation and completion of toilet training and duration of toilet training. The sample consisted of 406 children between 17 and 19 months of age, from a suburban private paediatric practice and 378 (93%) were followed by telephone interviews with parents. The finding suggest that age of initiation of toilet training was correlated with age of completion of training (r=0.275). The correlation between age at initiation of intensive training and age at completion was stronger (r=0.459). Age at initiation of intensive toilet training was negatively correlated with duration of toilet training (r= -0.481) which indicates that initiation of training at younger ages was associated with a longer duration of training.22

A study was conducted in 2002 to evaluate the age at which potty training readiness signs were attained among angawadi going children in Andhra Pradesh. It was found that girls started potty training at an average age of 23 months and 25 months for boys. The length of time to potty train two year olds ranged from 6.9-14.6 months. 23

A cross sectional descriptive study was conducted on factors associated with difficult toilet training to find out the temperament and behavioral patterns in children with difficult toilet training and to compare those children with same aged toilet trained children in Tanzania. The sample was clinical patients (n=46) and community preschoolers (n=62) and sampling technique used was convenience sampling. The data collection instrument was questionnaire which includes Carey-McDevitt Behavioural Questionnaire, Parenting Scale and a Toileting History Questionnaire. The findings suggest that comparison children had easy temperament clusters (42% of comparison children as compared with 2% of difficult toilet trainers) than difficult toilet trained children. Parenting style did not differ significantly between the two groups. 78% of difficult toilet trainers were constipated as compared with 55% of comparison children. In difficult toilet trainers, 74% hide stool and 37% ask for pull-ups.24

A retrospective study was conducted to reveal the importance of parental role in toilet training among mothers of underfive children in Kerala. The study enrolled children between the ages of 17–19 months of age. Children randomized to the treatment group received a three-prong intervention consisting of: 1) child-oriented toilet training guidelines, 2) parents only use positive words when referring to feces; and, 3) prior to toilet training, parents praise their child for defecating in their diaper. Children randomized to the control group received the same toilet training guidelines as the intervention group. While there was no difference in the incidence of Stool toileting refusal between groups, the duration of Stool Toileting Refusal and time to complete toilet training were significantly less among children in the intervention group. So he concluded that parental involvement is very important during the toilet training process.26

2. STUDIES RELATED TO TOILET TRAINING PROBLEMS

An analytical study was conducted among 5000 elementary school aged children for bladder control problems such as UTIs, bedwetting and daytime accidents in Melbourne . The study revealed that postpoding the onset of toilet training after 18 months of age and using certain methods to provoke voiding increases the risk of later problems with bladder control .It was found out that early potty training parent, whose children had fewer bladder problems, tended not to use child led potty training. They train their children by scheduling potty breaks and giving fluids on a schedule. For example, giving milk at lunch and then taking child to potty after lunch and about an hour later.27

. A study was conducted by Agency for Health Care Quality and Research (ARHQ) to review specifically address problems related to toilet training. The study revealed that approximately 2 to 3 percent of children develop problems during toilet training Difficult-to-train children are less adaptable, have a more negative mood, and are less persistent than easy-to-train children; no differences in parenting styles between easy- and difficult-to-train children are described. These children have higher rates of stool toileting refusal, stool withholding, or hiding during defecation.28

A retrospective study was conducted to gather data concerning bowel habits and toilet training of developmentally normal children ages 2 to 3 years in Ludhiana, Punjab. A questionnaire containing information on age, race, and sex was completed anonymously by a parent in 9 pediatric practices. When all of the children were considered together, toilet training started at a mean of 27.2 months and was completed at a mean of 32.5 months. Straining at defecation and infrequent stooling were reported significantly more often for girls, whereas staining of underclothes and passage of large bowel movements were reported more often in boys. It was concluded that most of the children between 2 and 3 years of age have a medium-size bowel movement daily or every other day without straining or withholding. Although African American children toilet training at an earlier age than do white children, bowel habits appear to be similar. A sizeable subgroup of children presenting to primary care providers have a history that is consistent with constipation.29

A retrospective study was carried to analyze the risk factors for recurrent urinary tract infection (UTI) and the possible influence of potty-training by using, a questionnaire with 41 questions among parents of children going in normal primary school in Chennai. Statistical analysis was done with the Chi-squared test and Yates correction. In the group with recurrent UTI, more parents asked the child to strain, made special noises or turned on a tap. The study concluded that daytime with/without night-time wetting, more than 10 voidings a day and nocturia are indicators of recurrent urinary tract infections. If they are simultaneously present, the relative risk for recurrent urinary tract infections is 60%, which is related to improper potty training.30

A retrospective study was conducted to analyze the changes in toilet training of children in Belgium in the last three generations and to seek a possible cause for the apparent increase in lower urinary tract dysfunction over that period. A questionnaire (25 questions) was developed and completed by 321 people who had toilet-trained 812 children. The population was divided into three groups according to the age of those who trained the children. The result was there has been a major change in toilet training in the last 60 years; the age at which toilet training began has been significantly postponed. The study concluded to start bladder training when the child stays dry during the afternoon nap and using bladder drill might help to avoid permanent bladder dysfunction. The lack of formal bladder training may be responsible for an increase in lower urinary tract dysfunction.31

A cohort study was conducted to analyzed the effects of early and late toilet training among 378 children in Bihar. The study found that toilet training was completed at a mean of 36.8 (range 22 to 54 months). Late toilet training (at least 42 months of age) was associated with a later mean age of initiating toilet training, lower language score at 18 months, stool toileting refusal, increased constipation, and hiding during toilet training. The study concluded that training children at a younger age, that is, between the ages of 18 and 26 months, resulted in a longer training duration; however, there were no adverse events (constipation, stool toileting refusal, stool withholding, or hiding during training) associated with early training.32

A prospective longitudinal study was conducted in Pennsylvania to investigate whether constipation and painful defecation occur due to stool toileting refusal or before stool toileting refusal. The sample was 380 children of age 17-19 months in Maharashtra. The data collection instrument was telephonic interview which was conducted every 2-3 months with the parents. The findings suggest that children with stool toileting refusal had demonstrated an increased incidence and frequency of having hard bowel movements. More than 90%of children had their first hard bowel movement before developing stool toileting refusal and more than 70% had painful bowel movements before developing stool toileting refusal. Children who had frequent hard bowel movements before the onset of stool toileting refusal demonstrated a longer duration of stool toileting refusal.33

A study was conducted on the prevalence of enuresis in school children and to determine the contributing factors and treatment methods in India. The sample consisted of parents of 1473 children in the age group of 6-10 years. Data was collected through a self administered semi-structured questionnaire. It was found out that overall prevalence of enuresis was 7.61% and was more common in boys. In the enuretic group, positive family history, family stressors and lower socio-economic status was present to a larger extent.34

3. STUDIES RELATED TO TOILET TRAINING METHODS

A study was conducted on the effectiveness of toilet training methods to find out optimal toilet training method for achieving bowel and bladder control. The population was 50 infant and 50 toddlers with or without co morbidities and behavioural handicaps. The study design was Randomised Controlled Trial. The findings suggest that for healthy and mentally handicapped children, Azrin and Foxx method proved to be better. For children with Hirschsprung’s disease, a multidisciplinary behaviour treatment is more efficacious than no treatment.35

A study was conducted to find out the best method of toilet training. The sample was 34 developmentally normal children in the age group of 20-36 months, who were considered difficult to toilet train. The findings suggest that toilet training was achieved in an average of 3.9 months using the Azrin and Foxx method. However negative outcomes of toilet training were also found to be rare at the four month follow-up. Although this method has been initially designed for bladder continence, it can also be used for bowel control.36

A cross sectional study was conducted to determine the patterns of toilet training and the factors that may be related to its timing and duration and the approaches of different sociocultural groups within a developing country in Tanzania. Cross-sectional survey was performed on 745 children who live in three different sociocultural settlements. The factors that might have affected initiation and completion age and duration of toilet training were assessed with t-test, ANOVA and logistic regression analysis. The duration of training was longer in families living in rural and semi-urban settlements, mothers educated for less than 5 years, unoccupied mothers, children living in houses which do not have a toilet inside, families who use washable diapers and when the initiation was before the child was 18 months old. It was concluded that Toilet training shows differences among cultures. The age of initiation may be increased as the parents are educated better and a child-orientated approach becomes more popular than the parent-orientated approach.37

A study was conducted to find out the age at initiation and completion of toilet training appears to be partially explained by race. The people begin toilet training within the first few weeks of life and expect the infant to be reasonably well trained between the ages of four to six months. Compared to other races, African-American children were found to start and complete toilet training at an early age. African-American children began toilet training at median of 21 months of age and were trained by 30 months. In contrast, Caucasian children commenced toilet training at 30 months and were trained at 39 months of age. When surveyed, 50 percent of African-Americans felt it was important their child be toilet trained by the age of two, while only 4 percent of Caucasian parents agreed with the statement. A second study surveyed four cultural groups in the United States to determine their beliefs regarding healthy infant and child development. European American mothers stated children were toilet trainable at 28.1 months of age, where as mothers felt children reached toilet training age between 20.2 & 22.2. It was concluded the race is dependent predictor for age of initiating toilet training.38

A prospective study was conducted using the child centred approach in middle class families in Raichur. The samples were children between 17 and 19 months of age. Parents began toilet training them at the mean age of 29 months. It was found that children who had started toilet training before 27 months of age had achieved urinary continence at the same time as those who started after 27 months.39

6.3. STATEMENT OF THE PROBLEM

A study to assess the effectiveness of structured teaching programme on knowledge regarding toilet training among mothers of toddlers in selected pediatric ward, Bangalore.

6.4. Objectives of the study

1. To assess the level of knowledge mothers of toddlers regarding toilet training.

2. To assess the effectiveness of structured teaching programme on Knowledge regarding toilet training among mothers of toddlers.

3. To determine the association between post-test knowledge score and selected demographic variables.

6.5. Operational Definitions

ASSESS

In the present study assess refers to the organized systematic and continuous process gathering information of knowledge on toilet training among mothers of toddlers.

EFFECTIVENESS

Effectiveness means the capability of producing an effect, and is most frequently used in connection with the degree to which something is capable of producing a specific, desired effect.

In this study it refers to the gains in the knowledge of mothers in relation to toilet training after the administration of structured teaching programme about toilet training to the toddler.

Toilet Training:

Toilet training refers to the process of training a child to control bladder and bowel movements and to use the toilet.

In this study it refers to the acquisition of skills necessary for urinating and defecating in a toilet at a socially acceptable time and age.

Toddlers:

It is a young child, usually defined as the ages of 1-3 years old.

KNOWLEDGE

Knowledge is a familiarity with someone or something, which can include information, facts, descriptions and skills acquired through experience or education.

In this study it refers to the awareness of mothers on toilet training as measured by the scores obtained according to the responses to the items in a structured knowledge questionnaire.

Structured Teaching Programme

It refers to a planned series of information to the group of people so as to help them to learn something.

In this study it refers to an educative material which provides information on toilet training on the following aspects such as meaning of toilet training ,timing of toilet training, toilet training methods , current recommendations , factors related to toilet training and effects of improper toilet training.

6.6 ASSUMPTIONS

➢ Mothers of toddlers possess some knowledge regarding importance of toilet training.

➢ Structured teaching programme regarding importance of toilet training will help them to improve the knowledge to follow during practice.

6.7 DELIMITATIONS

The study is limited to

➢ Mothers of toddlers.

➢ Pediatric wards of selected hospitals at Bangalore.

➢ Mothers who knows English and Kannada.

6.7 HYPOTHESES:-

There is a significant difference between pre test and post test mean knowledge score on knowledge regarding toilet training among mothers of toddlers.

7. METHODOLOGY:

7.1 Research Approach – An evaluative research approach.

7.2 Research design – One group pre-test and post-test experimental design.

7.3 Setting - The study will be conduct in pediatric ward at Yelanhanka General Hospital, Bangalore.

7.6 Populations – All mothers of toddlers.

7.5 Sample size – N=30

7.6 Sample Technique – Non- probabiltity convenient sampling technique.

7.7 INCLUSION AND EXCLUSION CRITERIA

1. Inclusion criteria:

A. Study participants who are having toddlers.

B. Study participants who are able to read and write kannada and English.

C. Study participants who are willing to participate in the study

2. Exclusion criteria:

A. Study participants who don’t know kanada and English

B. Mother with critically ill toddlers.

7.8 TOOL FOR DATA COLLECTION

The following tools will be used by the researcher exclusively for this study

• Tool 1: Socio demographic Proforma will be prepared by the investigator

• Tool 2: Questionnaire on toilet training will be prepared by the investigator.

7.9 VARIABLE:

Dependent Variable: Level of knowledge on toilet training among mothers of toddlers.

Independent Variable – STP on knowledge regarding toilet training.

Extraneous Variable – Age, Education, income, number of children, society, birth order etc.

7.10 METHOD OF COLLECTION OF DATA:

Prior to data collection, permission will be obtained from the concerned authority. After accepting the permission the following steps will be taken up the investigator.

Step 1 – Research introducer herself and explain the purpose of the study to the subjects

Step 2 – Administration of pretest on knowledge regarding TT.

Step 3 – introduces STP

Step 4 – Administration of post test on knowledge regarding TT.

The study period is 4-6 weeks.

7.11 METHOD OF DATA ANALYSIS:

Data will be analyzed by using descriptive and inferential statistics method:

(a)Descriptive statistics such as frequency, percentage, mean, standard deviation and paired‘t’ test

(b) Inferential statistic: Chi- square test will be used to find out the association between selected demographic variables with the level of knowledge among the study participants.

7.12 DELIMITATION:

The study is delimited to all the mother of toddlers in the selected hospital at Bangalore.

7.13 Does the study require any investigation or intervention to be conducted on patient or other human beings or animals?

- Yes, in this study intervention will be used to enhance the subject knowledge by administrating structured teaching programme.

7.16 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FORM THE INSTITUTION?

1) Permission will be obtained from the research committee of the Noor College of Nursing, Bangalore.

2) Written permission will be obtained from medical officer of Yelahanka General Hospital.

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|8 |SIGNATURE OF THE CANDIDATE | |

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|9 |REMARKS OF THE GUIDE | |

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|10 |NAME AND DESIGNATION OF | |

| |10.1 GUIDE | |

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| |10.2 SIGNATURE | |

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| |10.3 CO GUIDE | |

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| |10. 4 SIGNATURE | |

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|11 |11.1 HEAD OF THE DEPARTMENT | |

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| |11.2 SIGNATURE | |

|12 |12.1 REMARKS OF THE CHAIRMAN AND THE PRINCIPAL | |

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| |12.2 SIGNATURE | |

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