Form 10 IRB at Affiliate Institution

National Cancer Institute
Central IRB Initiative

OMB#: 0925 – xxxx Expiry Date: xx/xx/xxxx
STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized under 42 USC 285a. While your participation is completely voluntary, to
participate in the NCI CIRB, completion of this form is required. Data collected as part of the NCI CIRB review is private
and protected by law. Under the provisions of Section 301d of the Public Health Service Act, no information that could
permit identification of a participating individual may be released. All such information will be kept private under the
Privacy Act and will be presented only in statistical or summary form.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information 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.

IRB at Affiliate Institution
(All contact forms must be submitted by the local IRB of the signatory institution.)
Please provide information for each new IRB relying on an IRB from your signatory institution for review of
Cooperative Group studies approved by the CIRB. Contact information for Investigators and Research Staff
affiliated with each Institution is required. Please complete the “Investigator at Affiliate Institution” and “Research
Staff at Affiliate Institution” forms to provide this information.
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IRB Information at Affiliate Institution
IRB Name
IRB Registration Number
Is this IRB the IRB of Record for an entire Community Clinical
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating
CCOP institution (Yes/No)?
Is this IRB the IRB of Record for an entire for a Minority-Based
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating
MBCCOP institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
pediatric phase 2, 3 or pilot studies for a college, university, or
medical school? (Yes/No)
IRB Institution Information
Institution Name
NCI Institution Code

Name of CCOP
Name of CCOP
Name of MBCCOP

Name of MBCCOP
Name of Cancer Center
Name of College, University, or Medical School

FWA Number

Street Address
Street Address #2
City
State
Is this Institution a participating member of a CCOP? Yes/No

Zip
Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

National Cancer Institute
Central IRB Initiative

Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person
Name
First
Email Address
Telephone Number (
Remove IRB(s)
IRB Name

)

Last
-

Extension

IRB Registration Number

Institution Name