Screening Questions Containing Identifiable Information

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Institutional Review Board (IRB)
Division of Research
Office of Animal Welfare and Research Integrity
Room 130 Dyson Building
Tallahassee, Florida 32307-3800
irb@famu.edu
FORM G
SCREENING QUESTIONS CONTAINING IDENTIFIABLE INFORMATION
Form Instructions:
o This Form must be completed and submitted if the response to Question IV.H. in the IRB Application indicates
research involving collecting identifiers during screening.
o To complete the form, press TAB or SHIFT TAB between boxes and enter an ‘X’ or text. For assistance, contact
the Office for Animal Welfare and Research Integrity 850-412-5246
o Handwritten applications will NOT be accepted.
Project Title: _________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
Principal Investigator: _____________________________________________________________
Phone: ______________________________________________________________________
Email Address: _________________________________________________________________
1. How will the information obtained during screening be handled for individuals who qualify for the study? Choose
all that apply.
Store until the end of study & then destroy
Request permission from participant to maintain the information and to contact for future studies
Information will be handled in some other way  Explain: ______________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
2. How will the information obtained during screening be handled for individuals who DO NOT qualify for the study?
Choose all that apply.
Immediately destroy the information  Finished with Form G
Store until the end of study & then destroy  Finished with Form G
Use as “screening failure” data for investigator(s) listed on this application  Finished with Form G
Use as “screening failure” data & could be provided to others outside of the investigators listed on this
application  Answer Questions 3 – 4
Request permission from participant to maintain the information and to contact for future studies  finished
with
Form G
Information will be handled in some other way  Explain:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_____________________  Finished with Form G
3. Who outside of the investigators listed on this application will receive the data, in what form and why?

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