Mid Month Departmental Submission

IRB Protocol Deviation/Violation Report Form
Thank you for taking the time to engage with Mid Michigan College's Institutional Review Board (IRB). The IRB is responsible for reviewing all research projects submitted by College personnel to ensure the protection of human subjects' rights and welfare, and ensures that risks related to research are assessed and minimized, potential benefits are identified, participation is voluntary as demonstrated by informed consent, and confidential information is safeguarded.

Use this form to report any deviations from the approved project protocol, which may affect participants' rights, safety, or the integrity of the project data.

Questions? Email ir@midmich.edu for guidance.

Project Information

Welcome! Let's begin with some basic information.
Enter the title of your research project.*
Provide the title of your research project.
Enter the IRB Reference Number of your research project.*
This number is typically a TBD digit number in the following structure TBD.
What is the name of the Principal Investigator (PI)? This must be a Mid Michigan College faculty or staff member.*

First NameLast Name
What is the Mid Mich Email of the PI?*
example@midmich.edu
What is the Phone Number where the PI can be reached?*

Area CodePhone Number
Does your research project have a Secondary Investigator (SI)?*

YesNo
What is the name of the Secondary Investigator (SI)?*

First NameLast Name
What is the Email of the SI?*
example@example.com
What is the Phone Number where the SI can be reached?*

Area CodePhone Number

My signature below certifies that the information above is accurate and corresponds to the research project referenced.
Signature of the Principal Investigator*

Clear
Date*

MonthDayYear
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IRB Protocol Deviation/Violation Report Form