Vulnerable Population Research Safeguard Form

Research Project Information

Project Title Principal Investigator Name Email Address Institution / Organization Project Start Date Project End Date

Vulnerable Population Details

Describe the vulnerable population involved: Estimated Number of Participants

Research Purpose & Methods

Study Purpose Data Collection Methods

Risks & Safeguards

Potential Risks to Participants Safeguards to Minimize Risks

Consent & Confidentiality

Consent Procedure Confidentiality Measures

Ethics Review

Name of Ethical Review Board (if applicable) Approval Status Approved Pending Not Required