14a Study Review Responsibility Transfer Form (SRRT)

Study Review Responsibility Transfer Form

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Study Review Responsibility Transfer Form
OMB#: 0925 – 0625

Expiry Date: 01/31/2014

STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized under 42 USC 285a. Your participation is completely voluntary. You are subject to no penalty if you choose not to provide all or any part of
the requested information. Data collected as part of the NCI CIRB review is confidential 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 held in confidence 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 (0925-0625*). Do not return the completed form to this address.

Submission of this Study Review Responsibility Transfer Form indicates that the CIRB is
no longer the IRB responsible for review of this study. This is a two-step process. Step
1 is to complete this form, confirm the information, and submit. Step 2 is the CIRB
completion of the transfer.
Step 1: Complete this form.
Click “Confirm” once the form is completed and you will be taken to the confirmation page.
Note: If you wish to transfer more than one study, a separate request must be made for each study
being transferred.
Fields marked with * are required.
*Study Number: Select from the List
Study Title:
*Name of Local IRB: Select from the List
Institution’s FWA Number:FWA00005287
Local IRB Registration Number:
c Click this box if there are study participants enrolled at a site covered by this IRB.If so,upload a copy of the
d
e
f
g
IRB approval letter. NOTE: Your IRB must have approved the study via local procedures before transfer so there
is no lapse in IRB oversight of the study.
*Upload IRB Approval Letter:

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c Click this box if there are no study participants enrolled at a site covered by this IRB. NOTE: Proof that the
d
e
f
g
study is open is not required since there are no participants enrolled.

Confirm
If you wish to return to the Facilitated Review (FR) Submission Report, click the "Go Back" button
(all information entered will be lost). Go Back
If you have any questions or are having any difficulty completing this form, please call the NCI CIRB Helpdesk at
888-657-3711 or email [email protected]

http://www.ncicirb.org/members/SiteTransfers.asp

3/10/2011

Study Review Responsibility Transfer Form

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User Number: 370486
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http://www.ncicirb.org/members/SiteTransfers.asp

3/10/2011