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Center for Collaborative Intervention Research

Pilot Study Report Form

For instructions, download the Pilot Report Form Worksheet.

First Name:
Last Name:
Study Title:

1. Have you amended your consent form or study protocol?
No
Yes

2. Study Sample:

Total subjects consented*   Total subjects still active
Total women consented*    Total screen failures*
Total minorities consented*   Total withdrawals*
*Indicates cumulative total from start of study

Approximate ethnic makeup of population consented:
(Round off to the nearest percent, the total should add up to 100%)
Black: %   Asian: %   Pacific Islander: %
Hispanic: %   Caucasian: %   Middle Eastern: %
Native American/Native Peoples: %   Other: (specify) %

3. Have there been any unexpected study-related adverse events or unanticipated study-related problems which have not previously been reported to the IRB & the CCIR?
No
Yes
If "Yes" please send the completed form to CCIR@son.jhmi.edu.
Click here to download the form.

4. Have there been any unanticipated delays in the initiation or implementation of the project which have not been previously reported to the CCIR?
No
Yes

5. Is there any information you have not otherwise reported that summarizes study activity to date?
No
Yes

6. Have you met with the CCIR to review your study budget for this reporting period?
No
Yes
If "No" please make an appointment with Laura Neuberger.
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