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