PROTOCOL DEVIATION FORM - DOC

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					                 OHSU Research Integrity Office, Institutional Biosafety Committee, 3181 SW Sam Jackson Park Road, Mail code L106-RI, Portland, OR 97239-3098
                 Phone: 503-494-7887 ♦ Fax: 503-346-6808




PROTOCOL DEVIATIONS FORM
A protocol deviation occurs when there is an inconsistency in a research project between the protocol that has been reviewed and approved by the Institutional
Biosafety Committee (IBC) and the actual activities being done. Protocol deviations may be minor, moderate, or major. For detailed information, please read
the OHSU Policy on Protocol Deviations: http://www.ohsu.edu/xd/about/services/integrity/policies/research.cfm#ibc_policies

Report Date:                                           IBC#                                            Lab Location:
Principal Investigator                                                                                 Mail Code:
Lab contact:                                                                                           Phone number:

REPORT TABLE: To add a deviation, place the cursor in the cell and start typing: the cell will expand to accommodate your information. To add a new row,
place the cursor in the last cell of the last row and press the “Tab” key. You may attach additional documentation as needed.

                                                                Description of Protocol Deviation
Deviation
 number




                Date PD                                                    Resulted in harm to      Affected study      Number of          Please describe the plan for
                occurred              Brief description of PD                                                                                prevention of future PDs
                                                                            humans/animals?            results?         similar PDs




Principal Investigator’s Signature ___________________________________________________________________ Date_______________________




   OFFICE USE ONLY
       IBC Signoff ______________________________________________________________________________________ Date_________________________
                                                          Chair judgment                                        Corrective Action Required?
            Report Date ___________________
                                                           □ Minor      □ Moderate    □ Major       □ N/A            □ Monitoring     □ Probation   □ Suspension




9/22/08