Reporting Form for Research Concerns or Complaints

Name (optional or initials only):

May we reveal that you are the source of this concern or complaint to the study’s Principal Investigator and other study staff?

Yes

Personal Contact Information

(Required if you wish to hear back from us regarding this complaint)

Email Address:

Phone Number:

PLEASE NOTE: Unless you authorize us to do so, your personal contact information will not be released to anyone outside of the Human Research Protection Program.

Are you making this report for someone else?

Yes

Please Explain:

Study Information

Please tell us about the study for which you have a concern or complaint

Study Name or Description:

Name of Study Investigator(s):

Please tell us about the research concern or complaint you are reporting:

Please tell us how would like to see your concern or complaint resolved:

Have you discussed this concern or complaint with the Principal Investigator or other study staff?

Yes

Please let us know whom you contacted:

Are you or the person you are submitting this form for a participant in this study?

Yes

When did you start participating in the study?

(Please guess even if you can’t remember)

Are you still participating in the study?

Yes

Maureen Owens
Director Human Research Protection Program
Western Michigan University School of Medicine
1000 Oakland Drive
Kalamazoo, MI 49008
Office: 269.337.4269
Mobile: 616.808.9159
http//: wmed.edu/irb

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