{"id":1016,"date":"2022-04-25T10:52:10","date_gmt":"2022-04-25T14:52:10","guid":{"rendered":"https:\/\/research.ncsu.edu\/administration\/?page_id=1016"},"modified":"2022-10-19T15:55:18","modified_gmt":"2022-10-19T19:55:18","slug":"participant-concern-and-complaint-form","status":"publish","type":"page","link":"https:\/\/research.ncsu.edu\/administration\/compliance\/research-compliance\/irb\/irb-forms-and-templates\/participant-concern-and-complaint-form\/","title":{"rendered":"Participant Concern and Complaint Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_19_2'>\n                            \n                            <span id='input_19_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_19_2_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_19_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_19_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_19_2_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_19_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_19_3\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_3'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_19_3' type='tel' value='' class='small'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_19_4\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_4'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_19_4' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_19_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >May we reveal that you are the source of this concern or complaint to the study&#039;s Principal Investigator and other study staff?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_9'><li class='gchoice gchoice_19_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Yes'  id='choice_19_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_9_1' id='label_19_9_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='No'  id='choice_19_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_9_2' id='label_19_9_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you making this report for someone else?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_10'><li class='gchoice gchoice_19_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Yes'  id='choice_19_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_10_1' id='label_19_10_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='No'  id='choice_19_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_10_2' id='label_19_10_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_11\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_11'>If yes, please explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_19_11' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_19_13\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/>\n<hr \/>\n<h4>Study Information<\/h4><\/li><li id=\"field_19_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you know the study title?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_15'><li class='gchoice gchoice_19_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Yes'  id='choice_19_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_1' id='label_19_15_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='No'  id='choice_19_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_15_2' id='label_19_15_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_12'>Study Title<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_19_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_19_14\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_14'>If you do not know the title, describe what you think the study was about.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_19_14' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_19_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_24'>Name of Researchers<\/label><div class='gfield_description' id='gfield_description_19_24'>It is okay if you don't have this information.<\/div><div class='ginput_container ginput_container_text'><input name='input_24' id='input_19_24' type='text' value='' class='medium'  aria-describedby=\"gfield_description_19_24\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_19_31\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/>\n<hr \/>\n<h4>Details of Concern or Complaint<\/h4><\/li><li id=\"field_19_28\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_28'>Please tell us about the research concern or complaint you are reporting:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_19_28'>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.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_19_28' class='textarea medium'  aria-describedby=\"gfield_description_19_28\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_19_29\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Have you discussed this concern or complaint with the researcher or other study staff?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_29'><li class='gchoice gchoice_19_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Yes'  id='choice_19_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_29_1' id='label_19_29_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='No'  id='choice_19_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_29_2' id='label_19_29_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_30\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_30'>Who did you contact?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_19_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_19_18\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you or were you a participant in this study?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_18'><li class='gchoice gchoice_19_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Yes'  id='choice_19_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_1' id='label_19_18_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='No'  id='choice_19_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_18_2' id='label_19_18_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_23\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_23'>When did you start participating in the study?<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_19_23' type='text' value='' class='medium'  aria-describedby=\"gfield_description_19_23\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_19_23'>Please guess, even if you can't remember.<\/div><\/li><li id=\"field_19_19\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you still participating in the study?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_19'><li class='gchoice gchoice_19_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Yes'  id='choice_19_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_19_1' id='label_19_19_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='No'  id='choice_19_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_19_2' id='label_19_19_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a Consent Form for this study?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_19_20'><li class='gchoice gchoice_19_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Yes (if yes, please provide a copy to us)'  id='choice_19_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_20_1' id='label_19_20_1' class='gform-field-label gform-field-label--type-inline'>Yes (if yes, please provide a copy to us)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_19_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='No'  id='choice_19_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_20_2' id='label_19_20_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_19_21\" class=\"gfield 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