Clinical Trial Research Debriefing Form

Study Title Principal Investigator Participant Name / ID

Debriefing Information

Purpose of the Study Procedures Used Deception or Withheld Information (if any) Potential Risks or Discomforts Study Results / Findings (if available) Support and Resources

Contact Information

Primary Contact for Questions or Concerns Email Phone

Participant Acknowledgment

• I have been provided with information about the study and have had the opportunity to ask questions.
• I understand the purposes and procedures of the research.

Date Participant Signature