ࡱ> []ZW 3bjbj 4>aa $8 d&b  4&6&6&6&6&6&6&$'*Z&]D]"DDZ&E&"""D^84&"D4&"""oie^" &&0&"++ ++"++"Eh"TCZ&Z& !l&DDDD++B J:   Compliance Report The IRB strongly encourages faculty, staff, students, research participants or community members to report questionable practices/behaviors, accidents and unapproved actions. These reports are part of an internal quality improvement program and will not be released to anyone outside the պ Office of Research Integrity (ORI) unless it meets the definition of serious or continuing non-compliance. The Compliance Officer will work directly with the principal investigator to resolve any issue(s) or will present it to the Institutional Review Board should it involve serious or continuing non-compliance. Date of Incident:  FORMTEXT       Date of Report:  FORMTEXT       Principal Investigator:  FORMTEXT       IRB Protocol:  FORMTEXT       Individuals Involved (please provide first and last names and UAF status, if known):  FORMTEXT       Location of Incident (include facility name and room/pen number):  FORMTEXT       Incident Description (describe the events and your concerns as clearly and concisely as possible):  FORMTEXT       Was any corrective action taken by involved persons?  FORMCHECKBOX  None  FORMCHECKBOX  Verbal Notification Individual(s) Notified:  FORMTEXT       By whom:  FORMTEXT        FORMCHECKBOX  Written Notification Individual(s) Notified:  FORMTEXT       By whom:  FORMTEXT        FORMCHECKBOX  Re-training Describe:  FORMTEXT       By whom:  FORMTEXT        FORMCHECKBOX  Activity Stopped By whom:  FORMTEXT        FORMCHECKBOX  Other Explain:  FORMTEXT        FORMCHECKBOX  None to the best of my knowledge  FORMCHECKBOX  Unknown If personal injury (physical) resulted from the incident, was an HYPERLINK "http://www.uaf.edu/safety/incidentreport-2012.1.pdf"պ Accident/Incident Report Form filed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Not Applicable  FORMCHECKBOX  Unknown Who is reporting this incident? All պ employees are fully protected against reprisal as required byC D F T l + = > C H Q _   ɾxsxxldh}hT?5 hT?hx& hT?6hT?h L6hT?h1e6hT?h%(Q6hT?ho!6hT?h+6hT?h 6hq56CJ$aJ$h"56CJ$aJ$h L56CJ$aJ$hjh h CJU h aJ$ h CJjh LCJUjh CJUmHnHu& ` b  $ 4"`gdT?gdT?gd+$a$gdbgd     4 8 : N P R \ ^ `    4 ޮޛޮވphh}hT?6$jh}hT?B*Uph hT?5$jh}hT?B*Uph$jh}hT?B*Uphh}hT?5)jh}hT?B*UmHnHphu$jAh}hT?B*Uphh}hT?B*phjh}hT?B*Uph h}hT?( `bfh|~RTXZnpr|~ޮޓހxph`hT?hv5hT?hXy5hT?hEr5hT?hb5$jh}hT?B*Uph$jSh}hT?B*Uphh}hT?6h}hT?5)jh}hT?B*UmHnHphu$jh}hT?B*Uphh}hT?B*phjh}hT?B*Uph h}hT?" &(DFH *,.···|·n·[$j]hT?hT?B*UphjhT?hT?U$j}hT?hT?B*Uph)jhT?hT?B*UmHnHphu$jhT?hT?B*UphhT?hT?B*phjhT?hT?B*UphjhT?hT?Uj'hT?hT?UjhT?hT?U hT?hT?#FH\^`jlr "ȵȪӜȉvӪhj{hT?hT?U$jhT?hT?B*Uph$jhT?hT?B*Uphj1hT?hT?UjhT?hT?U$jhT?hT?B*UphhT?hT?B*ph hT?hT?jhT?hT?B*Uph)jhT?hT?B*UmHnHphu%"$&02468TVX~ !"#6Aݶݶ|nf^VhT?h1e5hT?h;5hT?hv5jhT?hT?Uj;hT?hT?U$jhT?hT?B*Uphj[hT?hT?UjhT?hT?UhT?hT?B*ph hT?hT?)jhT?hT?B*UmHnHphujhT?hT?B*Uph$jhT?hT?B*Uph!"#%@Al-n-P..///000001D1F1j111111gd+Ade#$&'567?@AE~ph`hT?hD4d5hT?hv5jz!hT?hs=U hT?h6j!hT?hs=Uj hT?hs=U hT?hvj hT?hs=U hT?h;jhT?h;UhT?h;0J5j'hT?h?}5UhT?h?}5jhT?h;5UhT?h;5$EQV_a*****++++H+J+z+|+~++,l,~,,,-h-l-n-p------.Ž׵םם׏ׇ|ug|u|uj!hT?hs=U hT?h jhT?h UhT?h+d 5hT?hg7f56B* phhT?hg6hT?hr|6hT?h}6hT?hA%6hT?ha6hT?h+d 6UhT?h-6hT?hg7f6hT?h 5hT?hD4d5hT?h65hT?h85% the Animal Welfare Act, 42 CFR Part 94 (Protection of Research Misconduct Whistleblowers), and Alaska Whistleblower Act (AS 39.90.100-150). Students are protected from reprisals arising from good faith reporting under Board of Regents Policy P09.01.09. The information requested in this section is strictly optional; please provide only the information with which you are comfortable. You may choose to submit this report anonymously.  FORMCHECKBOX  Primary Person Involved (self-reported)  FORMCHECKBOX  Supervisor or Principal Investigator  FORMCHECKBOX  Coworker  FORMCHECKBOX  ORI Staff  FORMCHECKBOX  Vet Services or Animal Facility Staff  FORMCHECKBOX  Other Facility User  FORMCHECKBOX  Other (explain):  FORMTEXT       Name (optional):  FORMTEXT       Phone (optional):  FORMTEXT       FOR OFFICE OF RESEARCH INTEGRITY USE ONLY Follow-Up Activities:  FORMTEXT       Final Resolution:  FORMTEXT           Send the completed form to the Office of Research Integrity Email: HYPERLINK "mailto:uaf-ori@alaska.edu"uaf-ori@alaska.edu Fax: (907) 474-5444 Mail: Suite 212 WRRB, P.O. 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