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Research Involving Human Subjects Form

A. Your Name
Name (Optional or Initials Only):
May we reveal that you are the source of this concern or complaint to the study’s Principal Investigator and other study staff?
B. Personal Contact Information (REQUIRED if you wish to hear back from us regarding this complaint)
Phone: Email Address:
Alternate Phone: Other Contact Info
Unless you authorize us to do so, your personal contact information will not be released to anyone outside the HRPP.
Are you making this report for someone else?
If Yes please explain:
C. Study Information
1. Please tell us about the study for which you have a concern or complaint:
Study Name or Description:
Name of Study Investigator(s): Study Phone Number:
2. Please tell us about the research concern or complaint you are reporting:
3. Please tell us how would like to see your concern or complaint resolved:
4. Have you discussed this concern or complaint with the Principal Investigator or other study staff?
If yes, please let us know who you contacted:
5. Are you or were you a participant in this study?
If yes, please answer questions a to d below:
a. When did you start participating in the study? (Please guess even if you can’t remember): Date:
b. Are you still participating in the study?
c. Do you have a consent form for this study?
If yes, please email a copy of the consent form.
d. Do you have any other written information about this study?
If yes, please email any other written info.
If you are unable to email, please wait for a staff member to contact you before providing these documents.
If you have additional comments or need additional space, please email additional sheets.