Form 2l IRB at Signatory Institution

IRB at Signatory Institution

(All contact forms must be submitted by the local IRB of the signatory institution.)

OMB#: 0925 – 0625

Expiry Date: 01/31/2014

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of your participation in the NCI CIRB is protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the NCI CIRB at any time. Refusal to participate will not affect your benefits in any way. The information collected will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the NCI CIRB. Information provided will be combined for all participants and reported as summaries. You are being requested to complete this instrument so that we can conduct activities involved with the operations of NCI CIRB Initiative.

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.

Please list IRB(s) at your signatory institution that currently review Pediatric and/or Adult Cooperative Group cancer treatment studies. Be sure to supply the OHRP IRB Registration Number for each IRB and whether each IRB will be reviewing Adult or Pediatric Cooperative Group treatment studies or both.
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IRB Information at Signatory Institution
Institution Name      
IRB Name      		OHRP IRB Registration Number      
Review Type (Adult, Pediatric, Both)	Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical Oncology Program (CCOP)? (Yes/No)		Name of CCOP      
Does this IRB serve as the IRB of Record for a participating CCOP institution? (Yes/No)		Name of CCOP      
Is this IRB the IRB of Record for an entire for a Minority-Based Community Clinical Oncology Program (MBCCOP)? (Yes/No)		Name of MBCCOP      
Does this IRB serve as the IRB of Record for a participating MBCCOP institution? (Yes/No)		Name of MBCCOP      
Does this IRB serve as the IRB of record for an NCI-designated Cancer Center? (Yes/No)		Name of Cancer Center      
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)		Name of College, University, or Medical School      

Remove IRB(s)

IRB Name	IRB Registration Number
     	     
     	     
     	     

(Internal use only)

Site GUID	     
TABLE	IRB