ANNUAL UPDATE ON ACTIVITIES APPROVED UNDER EXEMPTION Michigan Department of Health and Human Services Institutional Review Board for the Protection of Human Research Subjects 333 South Grand Avenue, PO Box 30195 Lansing, MI 48909 Email: Phone: 517-241-1928 Fax: 517-241-1200 SECTION 1 PROJECT IDENTIFICATION – 1.1 Project Title MDHHS IRB Log # Approval Expiration Date Responsible Department Employee Authorizing Supervisor Primary Investigator Primary Investigator Email 1.2 Indicate below if changes are needed to the contact information for the responsible department employee, the authorizing supervisor, and/or the primary investigator. Responsible Department Employee Name Phone Email Authorizing Supervisor Name Phone Email Primary Investigator Name Phone Email SECTION 2 PROJECT STATUS – 2.1 Is this research still ongoing? Yes No If please continue to 2.2. “Yes,” If indicate the date the activity ended: “No,” Note: If the activity has ended, you need not complete the remainder of the form. Please return this portion of the form to . 2.2 What is the projected date of completion? 2.3 Describe in the below any problems associated with the research that constitute a potential human subjects protection concern. Indicate if no problems occurred. 2.4 Describe in the space below any modifications to the research that could change the exempt status of the project (please consult a member of the MDHHS IRB if you need help determining what might affect exempt status). Indicate if no such changes occurred or are planned. Please complete and return this form to the MDHHS IRB 5 business days prior to approval expiration. Failure to provide a timely update on projects approved under an exemption by the MDHHS IRB is a violation of MDHHS policy. Completed forms may be sent by reply email to: The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. Authority: Code of Federal Regulations Title 45 Part 46
ANNUAL UPDATE ON ACTIVITIES APPROVED UNDER EXEMPTION Michigan Department of Health and Human Services Institutional Review Board for the Protection of Human Research Subjects 333 South Grand Avenue, PO Box 30195 Lansing, MI 48909 Email: Phone: 517-241-1928 Fax: 517-241-1200 SECTION 1 – PROJECT IDENTIFICATION 1.1 Project Title MDHHS IRB Log # Approval Expiration Date Responsible Department Employee Authorizing Supervisor Primary Investigator Primary Investigator Email 1.2 Indicate below if changes are needed to the contact information for the responsible department employee, the authorizing supervisor, and/or the primary investigator. Responsible Department Employee Name Phone Email Authorizing Supervisor Name Phone Email Primary Investigator Name Phone Email SECTION 2 – PROJECT STATUS 2.1 Is this research still ongoing? Yes No If “Yes,” please continue to 2.2. If “No,” indicate the date the activity ended: Note: If the activity has ended, you need not complete the remainder of the form. Please return this portion of the form to . 2.2 What is the projected date of completion? 2.3 Describe in the below any problems associated with the research that constitute a potential human subjects protection concern. Indicate if no problems occurred. 2.4 Describe in the space below any modifications to the research that could change the exempt status of the project (please consult a member of the MDHHS IRB if you need help determining what might affect exempt status). Indicate if no such changes occurred or are planned. Please complete and return this form to the MDHHS IRB 5 business days prior to approval expiration. Failure to provide a timely update on projects approved under an exemption by the MDHHS IRB is a violation of MDHHS policy. Completed forms may be sent by reply email to: The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. Authority: Code of Federal Regulations Title 45 Part 46
DCH-1279_603740_7.docx