Form 29 Attachmnt 13 Form 11a Subject Withdrawal Form

Form Approved

OMB Number 0925-XXXX

Exp. Date: XX/XX/XXX

Public reporting burden for this form is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

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:

Page 1 of 1 Form 11A: Subject Withdrawal From Version 2.0 01/05/2015