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Participant Concern and Complaint Form
Name
First
Last
Phone
Email
May we reveal that you are the source of this concern or complaint to the study's Principal Investigator and other study staff?
*
Yes
No
Are you making this report for someone else?
*
Yes
No
If yes, please explain:
Study Information
Do you know the study title?
*
Yes
No
Study Title
If you do not know the title, describe what you think the study was about.
Name of Researchers
It is okay if you don't have this information.
Details of Concern or Complaint
Please tell us about the research concern or complaint you are reporting:
*
Try and provide as much detail as you can or feel comfortable sharing. What was the study about? What occurred that you want to report? Was it something about the study itself or the researcher's behavior? If you would like to talk with somone, please email irb-director@ncsu.edu.
Have you discussed this concern or complaint with the researcher or other study staff?
Yes
No
Who did you contact?
Are you or were you a participant in this study?
Yes
No
When did you start participating in the study?
Please guess, even if you can't remember.
Are you still participating in the study?
Yes
No
Do you have a Consent Form for this study?
Yes (if yes, please provide a copy to us)
No
Do you have any other written information about this study?
Yes (if yes, please provide a copy to us)
No