ࡱ> []ZW 3bjbj 4>aa $8 d&b  4&6&6&6&6&6&6&$'*Z&]D]"DDZ&E&"""D^84&"D4&"""oie^" &&0&"++ ++"++"Eh"TCZ&Z& !l&DDDD++B J:   Compliance Report The IRB strongly encourages faculty, staff, students, research participants or community members to report questionable practices/behaviors, accidents and unapproved actions. These reports are part of an internal quality improvement program and will not be released to anyone outside the UAF Office of Research Integrity (ORI) unless it meets the definition of serious or continuing non-compliance. The Compliance Officer will work directly with the principal investigator to resolve any issue(s) or will present it to the Institutional Review Board should it involve serious or continuing non-compliance. Date of Incident:  FORMTEXT       Date of Report:  FORMTEXT       Principal Investigator:  FORMTEXT       IRB Protocol:  FORMTEXT       Individuals Involved (please provide first and last names and UAF status, if known):  FORMTEXT       Location of Incident (include facility name and room/pen number):  FORMTEXT       Incident Description (describe the events and your concerns as clearly and concisely as possible):  FORMTEXT       Was any corrective action taken by involved persons?  FORMCHECKBOX  None  FORMCHECKBOX  Verbal Notification Individual(s) Notified:  FORMTEXT       By whom:  FORMTEXT        FORMCHECKBOX  Written Notification Individual(s) Notified:  FORMTEXT       By whom:  FORMTEXT        FORMCHECKBOX  Re-training Describe:  FORMTEXT       By whom:  FORMTEXT        FORMCHECKBOX  Activity Stopped By whom:  FORMTEXT        FORMCHECKBOX  Other Explain:  FORMTEXT        FORMCHECKBOX  None to the best of my knowledge  FORMCHECKBOX  Unknown If personal injury (physical) resulted from the incident, was an HYPERLINK "http://www.uaf.edu/safety/incidentreport-2012.1.pdf"UAF Accident/Incident Report Form filed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Not Applicable  FORMCHECKBOX  Unknown Who is reporting this incident? 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Students are protected from reprisals arising from good faith reporting under Board of Regents Policy P09.01.09. The information requested in this section is strictly optional; please provide only the information with which you are comfortable. You may choose to submit this report anonymously.  FORMCHECKBOX  Primary Person Involved (self-reported)  FORMCHECKBOX  Supervisor or Principal Investigator  FORMCHECKBOX  Coworker  FORMCHECKBOX  ORI Staff  FORMCHECKBOX  Vet Services or Animal Facility Staff  FORMCHECKBOX  Other Facility User  FORMCHECKBOX  Other (explain):  FORMTEXT       Name (optional):  FORMTEXT       Phone (optional):  FORMTEXT       FOR OFFICE OF RESEARCH INTEGRITY USE ONLY Follow-Up Activities:  FORMTEXT       Final Resolution:  FORMTEXT           Send the completed form to the Office of Research Integrity Email: HYPERLINK "mailto:uaf-ori@alaska.edu"uaf-ori@alaska.edu Fax: (907) 474-5444 Mail: Suite 212 WRRB, P.O. 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