Upon completion of your research project, fill out this form and submit one electronic copy to AND one signed
paper copy (with original signatures) to the mailbox of the HSRB Co-Chair (Dr. Lindsay Kennedy, DWR 140).
 #:
Project Title:
 (if student research):
 
(If the research was not completed as planned, please explain. Use extra pages, if
Faculty Research
Class Assignment
 Thesis
Independent 
Did you receive  Research Funds?
Yes No
utside financial support (e.g.,
grant money)?(If YES, name the funding source.)
Participant Information:
Projected number of participants as approved by HSRB:
Participant Interaction
Age Category:
Records Only
13-17 years
5 
Did any participant suffer any unanticipated or serious
adverse event? (If YES, explain on separate sheet and attach.)
I understand I received HSRB approval for this project and time-frame. If I want to continue this project
or a new project, I must reapply and receive HSRB approval again.
Data was collected from:
Total number of participants from whom data was collected:
Before beginning this form, please make sure you are using the most recent version of Adobe Acrobat and can save your entries.
Was your research an NIH-funded clinical trial?
If YES, please submit confirmation of results reporting)
Yes No
Yes No