Form 11 Institution Affiliate Institution without an IRB

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.

Affiliate Institution Without an IRB
(All contact forms must be submitted by the local IRB of the signatory institution.)
Please provide information for each new institution without an IRB that is 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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Affiliate Institution Without an IRB Information
Institution Name
FWA Number

NCI Institution Code

Street Address
Street Address #2
City

State

Zip

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

Name of CCOP
Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Contact Person Information
Contact Person
First
Name

Last

Email Address
Telephone Number (
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Institution Name

)

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Extension

FWA Number