FOR OFFICE USE ONLY
SMU REB #:
DATE RECEIVED:
COMPLETION OF RESEARCH REQUEST FORM
Form 5- Faculty/Student/Staff
INSTRUCTIONS: Send request to ethics.continuingreview@smu.ca
Since one of the primary purpose of the REB is to protect human research participants, a project is deemed to be complete when involvement with and risk exposure
to participants has ended. If you have indicated that you are no longer recruiting participants and your data collection is complete, your file will now be closed upon
successful review of this request. Should wish to conduct research on this proposal again, please contact the Office of Research Ethics.
1. RESEARCH INFORMATION
a) SMU REB File #:
Affiliation:
Type of Research:
Choose one
b) Title of the Research:
c) Original REB clearance period:
From: (dd/mmm/yyyy)
To: (dd/mmm/yyyy)
d) Latest REB clearance period:
From: (dd/mmm/yyyy)
To: (dd/mmm/yyyy)
e) Have there been any unreported changes to the REB cleared proposal since the most recent
(original, modified or annually renewed) REB clearance?
Yes
No
Tip: Consider changes to the research methods, title of the research, informed consent process, supporting research documents, adverse event
reporting, changes to the data retention method and/or period of the data retention or whether personally identifiable information may be accessed
outside of SMU or Canada (if applicable), how records are destroyed (if so promised to participants) or de-identified at the end of the retention
period and the methods for dissemination of the research results to particiants, as promised in the informed consent process. Consider that local,
provincial and national regulations involving research and research ethics are routinely updated.
If yes, submit a MODIFICATION REQUEST FORM, (Form 2) along this request.
Form 2 Attached
N/A
3. INVESTIGATOR CONTACTS
FACULTY OR STAFF PRINCIPAL INVESTIGATOR / FACULTY SUPERVISOR
a) Role:
Choose one
Name:
Phone #:
Email:
STUDENT PRINICIPAL INVESTIGATOR
b) Name:
Email:
Phone #:
4. FUNDING STATUS
Unfunded
a)
SSHRC
NSERC
CIHR
Internal
Other
b) Grant Name:
c) Grant Number:
d) Funding Period:
From:
To:
5. RESEARCH COMPLETION DATE
(dd-mmm-yyyy)
(dd-mmm-yyyy)
(dd-mmm-yyyy)
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Both manual and electronic submission of requests are accepted.
1) Requests involving student research must be submitted by the faculty supervisor;
2) Original signature isnot required for electronic submission;
3) It is required that all fields be completed.
6. RESEARCH PROGRESS
a)
Research was terminated prematurely
Research was completed as planned
Research was extended
Other (Specify):
b) Number of participants initially planned to be recruited into the study:
Number Recruited:
c) Number of participants completed the research:
Date participation has ended:
(dd-mmm-yyyy)
d) Number of participants voluntarily withdrawn from the study or withdrawn by researcher:
Please specify reasons:
No participants withdrew from research participation
7. DISSEMINATION OF RESEARCH RESULTS
a) Briefly summarize or update the agreement between the researcher and the participants and the status of
dissemination of research results. Consider presented or planned events, the specified agreement with participants and
publication.
8. DATA RETENTION MANAGEMENT, TRANSFER AND CONFIDENTIALITY
Research records are to be managed in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans,
institutional regulations, and Nova Scotia's Personal Information International Disclosure Protection Act (PIIDPA), as well as other applicable
standards, including funding agency requirements (if applicable).
a) Please summarize: i, How ii, where and iii, for how long records will be managed or destroyed (if applicable) and iv,
describe applicable privacy protections that have been promised to research participants during the intial or later ongoing
informed consent process during the course of the research.
9. AGREEMENT
My signature certifies that the above information is correct, up-to-date and that no procedures were used in this study without REB
clearance. All adverse events and deviations to the originally submitted proposal have been reported to the REB, research results
have been or will be communicated to participants as promised during the informed consent process and proper safeguards relating
to confidentiality and security of research data will be maintained, data will be securely stored in accordance with the SMU REB
proposal and applicable guidelines legislation as demonstrated.
Signature of Faculty/Staff Principal Investigator
Date (dd-mmm-yyyy)
Signature of Student Principal Investigator
Date (dd-mmm-yyyy)
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