Form 5 Study Closure Report - Interior Health Research Ethics Board
Download a blank fillable Form 5 Study Closure Report - Interior Health Research Ethics Board in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 5 Study Closure Report - Interior Health Research Ethics Board with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Please complete and submit this form by
email to: researchethics@interiorhealth.caa
RESEARCH ETHICS BOARD
FORM 5
STUDY CLOSURE REPORT
To be submitted to the REB upon completion or early termination of research
1. IH File #:
2. Title of Project
3. Name of Principal Investigator
4. PI Address or Department & IH site
5. Phone Number
6. Fax Number
7. Email Address
8. Name & contact info of Primary Contact person if not PI
9. Name of IH Administrative Contact
10. Date this report was sent to IH Administrative Contact
Note: The PI must send a copy of this report to the IH Administrative Contact
11. Granting Agency/Source of funding:
12. Date of Study Closure or Early Termination
13. Principal Investigator Signature
__________________________________________
Date:
Signature
Summary of Research Participants Involved
14. Number screened:
15. Number enrolled.
16. Number of withdrawals and screening failures
17. Age range & gender of enrolled subjects
18. Number of deaths/early terminations
19. Number transferred into or out of this site
20. Number who completed the study
21. Number of local Serious Adverse Events
Version date: June 2012
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business