11a Subject Withdrawl Form

Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 11A: Subject Withdrawal form

Date of withdrawal: __ __ / __ __ / __ __ __ __
Initials of Research Coordinator: ________

(mm/dd/yyyy)

Method of withdrawal:

□ verbal (in person)
□ verbal (phone)
□ fax
□ email
□ Other, specify:_______________________
Reason for withdrawal from study:

□ Not interested in participating
□ Compensation not adequate
□ Other, specify: _________________________

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Form 11A: Subject Withdrawal From

Version 2.0
01/05/2015