Report Form for Research Concerns or Complaints

Institutional Review BoardReport Form for Research Concerns or Complaints

The Hunter College HRPP office is concerned about the safety, rights, and welfare of all individuals participating in research projects at Hunter College and its affiliated sites. If you have a research-related concern or complaint, please submit this form or contact us directly. Please provide as much information as you are able/comfortable.

You may choose to use this form to report a concern or complaint. There are three options for reporting:

Option 1: Once you submit the form it will get routed to our office.

Option 2: Report your concern or complaint directly, by calling (212) 650-3053.

Option 3: Mail a copy of the completed form to us at:

Hunter College HRPP Office
695 Park Ave, Room E1204
New York, NY 10065

Important Note on Confidentiality:
All research complaints are taken very seriously. The information you provide will be kept confidential. We may need to share this information with others in order to follow-up with your concern or complaint.

1) Name and Consent Information

Please complete the information below.
Note: You are not required to enter your name for a report, unless you wish to share that information. You may enter a full name, a partial name, or use your initials only.
Name Name First Last
May we reveal your name to the principal investigator or other study staff regarding this complaint or concern?

May we reveal your name to the principal investigator or other study staff regarding this complaint or concern? Yes No
Are you making this report for someone else?

Are you making this report for someone else? Yes No
If you are making this report for someone else, please explain:
Please provide the contact of the person directly (Name and Number/Email)
2) Personal Contact Information

This section is required if you wish to be contacted regarding this complaint or concern.
NOTE: Unless you agree, we will not share your personal information outside the HRPP/IRB.
Phone Number: Phone Number: - ### - ### ####
Email
Alternate Phone Number: Alternate Phone Number: - ### - ### ####
Other contact information:
May we share your personal information outside the HRPP/IRB regarding this complaint or concern?

May we share your personal information outside the HRPP/IRB regarding this complaint or concern? Yes No
3) Study Information

Please tell us about the study which you are reporting this complaint for:
Principal Investigator or other study staff:
Name of study:
Have you contacted the Principal Investigator or other study staff?

Have you contacted the Principal Investigator or other study staff? Yes No
Please state who you contacted:
Email filed:
Study phone number (found in your consent form): Study phone number (found in your consent form): - ### - ### ####
Is the complaint related to the compensation offered for completing the survey?

NOTE: To ensure data quality, any attempts to complete a survey multiple times or engage in fraudulent activities will result in the forfeiture of compensation.

Is the complaint related to the compensation offered for completing the survey?

NOTE: To ensure data quality, any attempts to complete a survey multiple times or engage in fraudulent activities will result in the forfeiture of compensation. Yes No
Please briefly describe your concern or complaint:
Please briefly explain how you would like us to help resolve this concern or complaint:
Are you or were you a participant in this study?

Are you or were you a participant in this study? Yes No
Are you reporting for someone else? If yes, please provide their name and number/email.
If you are a participant – please estimate a date when you started this study (does not have to be an exact date):
If you are a participant - are you still participating in the study?

If you are a participant - are you still participating in the study? Yes No
If you are a participant - do you have a consent form for this study? If yes, please provide a copy of what written documents you might have.

If you are a participant - do you have a consent form for this study? If yes, please provide a copy of what written documents you might have. Yes No
Please provide a copy of the consent document.

Maximum file size: 3MB.

Attach Files
4) Additional Information:
Please use this space to provide any additional information you wish to share. You may also attach extra sheets of paper if you need additional space.
5) Attachment:
Please attach any additional documentation as it relates to the concerns or complaints of the research study.

Maximum file size: 3MB.

Attach Files