Research Study Participant Discharge Form
Please complete this form to finalize your discharge from the research study.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Study Title
*
Study ID or Reference Number
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Discharge
*
Study completed
Participant withdrew
Medical or safety concerns
Non-compliance with study protocol
Other
Summary of Participation (e.g., sessions attended, milestones achieved)
Have all study materials or devices been returned?
*
Yes, all materials returned
No, some materials outstanding
Please indicate if you require any follow-up support or have post-study concerns.
Discharge Checklist
Received post-study instructions
Provided feedback on experience
Confirmed contact information for future correspondence
Participant Signature
*
Submit Discharge Form
Submit Discharge Form
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