Investigator Signature Only the PI Can Sign Date

Investigator Signature Only the PI Can Sign Date

<p> 5300 Beach5300 Blvd.,Beach Ste.Blvd., 110, PMBSte. 607 110, PMB 607 Ph: (714)Ph: 562-(714) 0526562- Buena0526 Park,Buena CA 90621-Park, CA 124990621- 1249</p><p>SITE FINAL Fax: REPORT FORM (866)Fax: 872-(866) This form is to be 0526872- submitted only if all subject Website:0526 participation is complete, no study w wWebsite: w .irbco.com activity is being conducted, no w w w .irbco.com analysis of data from this site remains, and no private identifiable health Email: information is being collected. Note: irb@irbcEmail: Selecting this o.comirb@irbc option will terminate o.com your IRB approval. No study- related activity may occur without IRB approval.</p><p>Principal Investigator (PI): IRB No.: Protocol No.: </p><p>Study Title: </p><p>Sponsor: Expiration Date: </p><p>1. Number of subjects enrolled since the beginning of the study. </p><p>2. Number of subjects completed. 3. Please provide a summary of the withdrawals from the research (both subject and investigator initiated) since the beginning of the study. Include the number and reasons for withdrawal.</p><p>4. Number of subjects lost to follow-up since the beginning of the study. </p><p>5. Subject Transfers:</p><p>5a. Number of subjects who have transferred in since the beginning of the study </p><p>5b. Number of subjects who have transferred out since the beginning of the study. </p><p>6. Please provide a summary, including the number, of serious adverse events or unanticipated problems, particularly risks to subjects and/or others that have occurred since the beginning of the study.</p><p>Page 1 of 2 [Version 03.01.2013] 7. Please provide any relevant multicenter trial reports (serious adverse event reports, Data Monitoring Committee reports or other reports) that have not been previously submitted through a report form.</p><p>8. Please provide a summary of any complaints from the subjects about the research since the beginning of the study.</p><p>9. Please provide a summary of any findings, literature, or other relevant information you learned through the study.</p><p>By signing, I certify under penalty of perjury that the information entered on this document is true and correct.</p><p>______Investigator Printed Name</p><p>______Investigator Signature – Only the PI can sign Date </p><p>Page 2 of 2 [Version 03.01.2013]</p>

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