Protocol #: Date form completed: Protocol Title: Principal Investigator: The information provided in this form should be in accordance with the Data and Safety Monitoring Plan written in the protocol. Submit completed form and attachments to Clinical Research Support at Submission due date: A. Does the research involve an independent safety monitoring committee or Data Safety Monitoring Board (DSMB)? Yes No* If yes: Monthly Every 3 months How often does the Every 6 months committee or DSMB meet? Every 9 months 12 months Please submit a copy of all results/minutes from the past 12 months. Next review will *If no, please continue to complete pages 2-4.
Protocol #: Date form completed: Protocol Title: Principal Investigator: The information provided in this form should be in accordance with the Data and Safety Monitoring Plan written in the protocol. Submit completed form and attachments to Clinical Research Support at Submission due date: A. Does the research involve an independent safety monitoring committee or Data Safety Monitoring Board (DSMB)? Yes No* If yes: How often does the committee or DSMB meet? Please submit a copy of all results/minutes from the past 12 months. Monthly Every 3 months Every 6 months Every 9 months 12 months Next review will *If no, please continue to complete pages 2-4.
01312_DSMC_Annual_Renewal_Form.docx