Study Termination Visit Form
Complete this form to document the essential details of a study termination visit.
Participant Name
*
First Name
Last Name
Participant Study ID
*
Study Title or Protocol Number
*
Termination Visit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Study Termination
*
Please Select
Study completed
Participant withdrew consent
Lost to follow-up
Protocol deviation
Other
Study Completion Status
*
Completed as planned
Terminated early
Study Materials Returned
Device(s)
Medication
Diary/Logbook
Other
Were there any adverse events or concerns?
*
No
Yes (please describe below)
If yes, describe adverse events or concerns
Final Comments
Submit
Should be Empty: