UNANTICIPATED PROBLEM INVOLVING RISK TO SUBJECTS OR OTHERS

REPORT FORM

This form is to be used to report any issues that are related to the safety, rights and welfare of study subjects. Please complete this form and submit within 10 calendar days from the date of discovery.

This includes the reporting of AEs, SAEs, UAEs, SUSARs, Protocol Deviations/Violation, which includes Drug or Device.

PART A

Unanticipated/Unexpected:

YESThis event has not been previously mentioned in the IB, Safety Letters, ICF or protocol, or is the frequency and/or severity more than initially documented or expected?

Increased Risk:

YESDoes this event increase the risk to the study subject or others?

Study Drug/Device or Study Related:

YESIs this event related to the study product and/or study participation(including wash-out periods)? Is there evidence the event was caused by the study product and/or study participation (other than just occurring while on study)?

If you have answered YES to ALL of the above questions, please continue to PART B of this form.

If you have not answered YES to ALL of the above questions, this event does not require reporting to Aspire. However, this does not mean this event does not require reporting to the CRO/Sponsor.

PART B

UNANTICIPATED PROBLEM INVOLVING RISK TO SUBJECTS OR OTHERS

This form is to include the reporting of events that affect the safety, rights and welfare of study subjects

All reports to the IRB should explain clearly why the event /problem is "unanticipated" and why the event represents a “problem involves increased risk(s) to the subject or others.”

NAME OF PRINCIPAL INVESTIGATOR:

SPONSOR NAME:

PROTOCOL NUMBER:

STUDY DRUG/DEVICE:

SUBJECT ID:

DATE OF REPORT: DATE OF OCCURRENCE:

DID THIS INCIDENT HAPPEN TO A STUDY SUBJECT WHILE ENROLLED AT YOUR SITE? YES NO

HAS THIS INCIDENT BEEN REPORTED TO THE FDA? YES NO

HAS THIS INCIDENT BEEN REPORTED TO THE SPONSOR? YES NO

Describe Unanticipated/Unexpected Event/Problem (include relevant dates)

Treatment / Outcome (include relevant dates):

Pertinent subject history (if applicable):

Why do you consider the incident “Unanticipated/Unexpected”?

How does this event suggest that subjects or others are at greater risk of harm than was previously known? **

** Please note: Reports of unanticipated problems to Aspire should include a corrective action plan for the issue, or an explanation for why none is provided.

What actions will be taken with the study in response to this problem? (Please note that an Unanticipated Problem typically requires at least one of the following.):

Change in the conduct of the study (amendment, suspension of enrollment,
etc). Please specify:

Revision of the Informed Consent document

Other action:

Printed Name of Person Completing Form / Company/Title
Phone number / Fax number / E-mail

Federal Regulation 21 CFR 56.108(b)(1), 21 CFR 812. and 45 CFR 46.103(b)(5) require IRBs to “follow written procedures for ensuring prompt reporting to the IRB…any unanticipated problems involving risks to human subjects or others...”

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Version date: May 1, 2013