RESEARCH ETHICS BOARD

FINAL REPORT OF AN APPROVED PROTOCOL

For Administrative Use Only

Date Received: / Completion Date: / Original Approval: / PROTOCOL #

IMPORTANT PLEASE READ: All relevant sections of this form must be completed. Attached documents may not be used instead of the standard form(s). Final Reports must be submitted for all completed protocols on or before the expiry date noted on the Letter of Certification. Applicants are advised to familiarize themselves with this document.

Any personal information collected on this form will form part of the records held in the Research Services Office and will be used to assist in the administration of your research program. A copy of this form may be reviewed by external parties in order to meet legislative, audit and/or regulatory requirements. If you have any questions or concerns about the information collected, please contact the Ethics Coordinator at 705-474-3450 ext. 4055.

1.0APPLICANT (Principal Investigator)

Please provide your permanent mailing address (including postal code): / Department /Faculty
Name:
Address:
E-mail Address:
Telephone Number (daytime):

1.1

Title of Research Project:
Protocol Number: / Start Date of Research:
Completion Date of Research:

1.2

NAME AND CONTACT INFORMATION / Department
Faculty Co-Investigator(s)
Faculty Supervisor (in the case of student research)

2.0PARTICIPANT INFORMATION

  • Total number of participants that have completed the study
  • Number of participants that have withdrawn from the study

If the withdrawal rate was higher than anticipated please describe any known circumstances.

3.0PROJECT INFORMATION

  • Have any research participants suffered any serious or unexpected harm? Yes No
  • Have any ethical concerns arisen while conducting this research? Yes No
  • Since the original ethics approval was granted, have there been any unidentified risks or benefits to participants? Yes No

If you answered Yes to any of the above questions, please provide details and what safeguards were provided to participants.

4.0RECORD RETENTION

Please provide specific details as to the disposal of data collected in this project (records, video, audio, data, etc.) and/or the time frame for record retention?

SIGNATURES:

Principal Investigator:

I certify that the information provided in this Final Report is complete and accurate. I understand that I had the ultimate responsibility for the conduct of the study, the ethics performance of the project, and the protection of the rights and welfare of research participants. I have complied with the Tri-Council Policy Statement and Nipissing University policies and procedures governing the protection of human participants in research.

Signature of Principal Investigator

Date

Faculty Supervisor Assurance: For student applications

I have read this Final Report and deem it to be complete. I understand if this report is incomplete it will be returned to me and I will be responsible for ensuring its completion

Signature of Faculty Supervisor

Date

Please complete and submit one (1) signed original and one (1) electronic version of the Final Report to

Ethics Administrator

Room F309

Fax: (705) 474-5878

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Final Report Feb15