**[Institutional Review Board (IRB)]{.smallcaps}**

**[Request for Termination of Protocol]{.smallcaps}**

**Date Rec'd in HSO [ ]{.underline}**

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| +                                                                    |
| -------------------------------------------------------------------+ |
| |                                                                    |
|  +-----------------------------------------------------------+---+ | |
| |                                                                    |
|  | **Instructions**: Use this form when terminating          |   | | |
| |                                                                    |
|  | (completed/withdrawn/canceled) a protocol. Please submit  |   | | |
| |                                                                    |
|  | this form electronically to the CIO designated staff      |   | | |
| |                                                                    |
|  | official. However, if submitted in hardcopy, please send  |   | | |
| |                                                                    |
|  | the original and one copy to the CIO designated staff     |   | | |
| |                                                                    |
|  | official. Complete all applicable items or the form will  |   | | |
| |                                                                    |
|  | be returned.                                              |   | | |
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|  +-----------------------------------------------------------+---+ | |
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|  |                                                           |   | | |
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|  +-----------------------------------------------------------+---+ | |
| |                                                                    |
|                                                                    | |
| |                                                                    |
|  **Date Submitted by Investigator:** [ ]{.underline}               | |
| +                                                                    |
| -------------------------------------------------------------------+ |
|                                                                      |
| **[Protocol No.]{.smallcaps}** [ ]{.underline}                       |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**Title of Protocol:**

  -- --
     
     
  -- --

**Name of CDC Employee Serving as Principal Investigator (PI) and
Degrees:**

  --------------------------- --
  9 Check if PI has changed   
                              
  --------------------------- --

*Scientific Ethics* Verification No.: [ ]{.underline} Telephone: [
]{.underline} Fax: [ ]{.underline}

  --------------------------------------------------------------------------------------------------------------- --
  **CIO**: [ ]{.underline} **Division**: [ ]{.underline} **MS:** [ ]{.underline} Email Address: [ ]{.underline}   
                                                                                                                  
  --------------------------------------------------------------------------------------------------------------- --

**1. Current status:**

[ ]{.underline} CANCELED (Never started) (Attach explanation)

  --------------------------------------------------
  [ ]{.underline} COMPLETED (Complete items 2,3,4)
  --------------------------------------------------

**2. Disposition of Data:**

[ ]{.underline} Original data and/or research materials have been
destroyed

[ ]{.underline} Linkage between existing data and original source of
information has been destroyed.

No individuals can be identified from existing data.

[ ]{.underline} Data with identifiers or linkage will be retained.
Indicate:

***Why:***

***Where:***

***How long***:

  --
  --

**3. Study Population **(If an international study, provide
race/ethnicity of subjects by percentages):

[ ]{.underline} Enrolled this past year

[ ]{.underline} Declined enrollment this past year

[ ]{.underline} Total number of subjects to date

[ ]{.underline} Withdrawn from project this past year

**For individuals who were enrolled this year:**

Gender distribution:

[ ]{.underline} % Female [ ]{.underline} % Male

**Race/ethnicity distribution of enrolled subjects for domestic
studies:**

[ ]{.underline} % American Indian or Alaskan Native

[ ]{.underline} % Asian or Pacific Islander

[ ]{.underline} % Black or African American, not of Hispanic

origin

[ ]{.underline} % Hispanic

[ ]{.underline} % White, not of Hispanic Origin

  --
  --

**4. Final Report** (Attach a copy of the final report for a completed
study)

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| +---------------------------------------------------+ |
| | +-----------------------------------------------+ | |
| | |   --                                          | | |
| | |   --                                          | | |
| | |                                               | | |
| | | **Approvals** (Signature and Position Title): | | |
| | +-----------------------------------------------+ | |
| |                                                   | |
| | **Date:**                                         | |
| +---------------------------------------------------+ |
|                                                       |
| **Remarks:**                                          |
+-------------------------------------------------------+
|                                                       |
+-------------------------------------------------------+

Branch Chief:

  -- -- --
        
        
  -- -- --

Division Director:

  -- -- --
        
        
  -- -- --

CIO Human Subjects Contact:

  -- -- --
        
  -- -- --