Form 2n IRB at Affiliate Institution

IRB at Affiliate 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 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)					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      
IRB Institution Information
Institution Name      
NCI Institution Code      					FWA Number      
Street Address      
Street Address #2      
City      			State   				Zip      
Is this Institution a participating member of a CCOP? Yes/No						Name of CCOP      
Is this Institution a participating member of a MBCCOP? Yes/No						Name of MBCCOP      
Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person Name	First      			Last      
Email Address      
Telephone Number (   )   -    		Extension      

Remove IRB(s)

IRB Name	IRB Registration Number	Institution Name
     	     	     
     	     	     
     	     	     

Internal use only)

Site GUID	     
TABLE	OIR