Participant Name:

Participant ID:

Date of Debriefing:

Study Title:

Study ID/Number:

Principal Investigator:

Purpose of the Study:

Summary of the Participant’s Involvement:

Any Deception Used (and Explanation):

Additional Information Provided to the Participant:

Contact information for Future Questions or Concerns:

Referral Resources (if applicable):

Participant Comments:

Debriefed By (Name/Signature):

Clinical Trial Post-Study Debriefing Form