Fillable IRB ParticipantWithdl Complaint Form - Participant Withdrawal Complaint Form

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IRB ParticipantWithdl Complaint Form - Participant Withdrawal Complaint Form

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Standalone Version 09/01/07
1
VALENCIA COMMUNITY COLLEGE
Human Research Protection (HRP) Institutional Review Board (IRB)
Participant Withdrawal/Complaint Report Form
(Internal and External Investigators)
NOTE: The form is subject to the disclosure requirements of Florida Sunshine Laws.
SECTION 1 – Withdrawal information to be completed by the Principal Investigator
Participant Initials: ___________________________________________________________________
Check all that apply:
Withdrawal
Effective Date of Withdrawal: ____________________________________________________________
Reason for Withdrawal (attach additional documents if necessary):
SECTION 2 – Complaint information to be completed by the Participant
Complaint
Participant Name: ____________________________________________________________
(optional)
Participant Signature: _______________________________ Date: ____________________
(or Parent/Guardian/Legal Rep)
(optional)
Description of Complaint (attach additional documents if necessary):
Participants may choose to submit the Complaint directly instead of giving it to the Investigator by mailing it
to: IRB Chair, Valencia Community College, P.O. Box 3028, Mail Code 3-32, Orlando, FL 32802.
Principal Investigators must submit Withdrawal forms to the IRB within thirty (30) working days of
occurrence or knowledge of occurrence, and must submit Complaint forms to the IRB within five (5) working
days of receipt.
Standalone Version 09/01/07
2
SECTION 3 – to be completed by the Principal Investigator
Title of Research Protocol: ___________________________________________________________________
Principal Investigator: ___________________________________________________________________
Mail Code: ____________________ Campus Phone: _____________________
PI Signature: _____________________________ Date: ___________________________
SECTION 4
Supervisor/Administrator: ___________________________________________________________________
Mail Code: ____________________ Campus Phone: _____________________
Supervisor/Administrator Signature: ________________________________ Date: _____________
All Participant Withdrawal Report Forms are reviewed by the full IRB for discussion and recommendation at
the next scheduled meeting. All Participant Complaint Forms are reviewed by the full IRB for discussion and
recommendation at the next scheduled meeting, or earlier.
If you have any remaining questions about Valencia’s IRB process, contact the IRB Chair at irb@valenciacc.edu .
THANKS!
______________________________________ ___________________
Date Received by IRB Chair or Designated Rep Date Distributed to IRB
IRB Recommendation: _______ No action at this time
Date:______________ _______ Changes to Consent Form
_______ Reconsenting
_______ Referral to (specify): _______________________________
_______ Other (specify): ___________________________________
IRB Comments:
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IRB ParticipantWithdl Complaint Form - Participant Withdrawal Complaint Form

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Completed 7 May 2020

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