Version 07/15/11
SECTION 3 – to be completed by the Principal Investigator
Title of Research Protocol: ___________________________________________________________________
___________________________________________________________________
Principal Investigator: ___________________________________________________________________
Address: _______________________________________________ Phone: _____________________
PI Signature: ______________________________________________ Date: _____________________
SECTION 4
Supervisor/Administrator: ___________________________________________________________________
Address: _______________________________________________ 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@valenciacollege.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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