Reporting Form for Research Concerns or Complaints

You may choose to use this form to report a concern or complaint. You can send us this form in one of two different ways:

  • By email: irb@wmed.edu
  • By US mail:
    Western Michigan University Homer Stryker M.D. School of Medicine
    WMed Human Research Protection Program
    Attn: Director, Human Research Protection Program
    1000 Oakland Drive
    Kalamazoo, MI 49008

You may choose to use this form to report a concern or complaint or
here are two additional ways you can choose to report a concern or complaint as follows:

  • Report your concern or complaint by phone by calling 269-337-4269.
  • Send a letter to the above address to report your concern or complaint. If you send us a letter, you may find it helpful to use the questions in this form as a guide for the content of your letter.

Important Note: All research concerns and complaints are taken very seriously. The information you provide on this form will be kept as confidential as possible. However, we may need to share this information with others in order to follow-up with your concern or complaint.

 

PLEASE COMPLETE ALL OF THE FOLLOWING INFORMATION:

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

Personal Contact Information

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

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?

 

Study Information

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

Have you discussed this concern or complaint with the Principal Investigator or other study staff?
Are you or the person you are submitting this form for a participant in this study?
(Please guess even if you can’t remember)
Are you still participating in the study?
Do you have a consent form for this study?
One file only.
6 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

 

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