Fillable SMUREB Form5 (St. Mary's University)

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SMUREB Form5 (St. Mary's University)

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Country of origin: CANADA
File type: PDF

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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 (only)
Completion Request: 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. Should you re-start your research, please complete a new application.
1) Requests involving student protocols must be submitted by the Faculty Supervisor;
2) All fields must be completed, otherwise will need to be sent back to sender.
1. RESEARCH PROJECT
a) SMU REB File #:
Affiliation:
Type of Research:
Choose one
b) Title of Research:
c) Original Approval Date:
From: (dd/mmm/yyyy)
To: (dd/mmm/yyyy)
d) Last Approval Period:
From: (dd/mmm/yyyy)
To: (dd/mmm/yyyy)
e) Have there been any unreported changes to the REB approved protocol since the most recent
(original, modified or annually renewed) approval?
Yes
No
Consider the study protocol, changes to the title of the research, consenting process, supporting documents, adverse event reporting, changes to
the retention method and/or period of retention, whether personally identifiable information may be accessed outside of SMU or Canada (if
applicable), how records are destroyed or de-identified at the end of the retention period and dissemination of research results to particiants, as
promised. Consider that local, provincial and national regulations involving research and research ethics are regularly 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 / STUDENT SUPERVISOR
a) Role:
Choose one
Name:
Phone #:
Email:
STUDENT PRINICIPAL INVESTIGATOR
b) Name:
Email:
Phone #:
4. FUNDING
Unfunded
a)
SSHRC
NSERC
CIHR
Internal
Other
b) Grant Name:
c) Grant Number:
d) Funding Period:
From:
To:
5. STUDY COMPLETION DATE
(dd-mmm-yyyy)
(dd-mmm-yyyy)
(dd-mmm-yyyy)
Page 1 of 2
6. STUDY PROGRESS
a)
Study was terminated prematurely
Study was completed as planned
Study was extended
Other (Specify):
b) Number of participants initially planned to be recruited into the study:
Number Recruited:
c) Number of participants completed the study:
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 study participation
7. DISSEMINATION OF RESEARCH RESULTS
a) Summarize/update the agreement between the researcher and participants and the status of dissemination of
research results. Consider presented/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 SMU REB Data Storage Guidelines, the Tri-Council Policy Statement: Ethical Conduct for
Research Involving Humans and Nova Scotia's Personal Information International Disclosure Protection Act (PIIDPA), other applicable standards,
including funding agency requirements (if applicable).
a) Summarize i, How ii, where and iii, how long records will be managed or destroyed (if applicable) and iv, describe
applicable privacy protections.
9. AGREEMENT
My signature certifies that the above information is correct, up-to-date and that no unapproved procedures were used in this study. All
adverse events and deviations have been reported to the REB, research results have/will be communicated to participants as
promised and proper safeguards to confidentiality and security of data will be maintained, data will be securely stored in accordance
with SMU REB policy and applicable guidelines legislation.
Proper safeguards to confidentiality and security of data will be maintained until all data are destroyed.
Signature of Faculty/Staff Principal Investigator
Date (dd-mmm-yyyy)
Signature of Student Principal Investigator
Date (dd-mmm-yyyy)
Page 2 of 2
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SMUREB Form5 (St. Mary's University)

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Completed 21 July 2020

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