Form 2a Request for 30 Day Website Access Form

Page 2

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.

Request for 30-Day NCI CIRB Website Access

The NCI CIRB Operations Office will provide 30-day access to the Participant’s Area of the CIRB website for those IRBs that are interested in joining the Initiative. Local IRBs have requested short-term access to the restricted side of the CIRB website so they may access review documents prior to enrolling in the CIRB Initiative. By completing and signing this request, you acknowledge that you are being given access to confidential information. These documents are for your information regarding participation in the NCI CIRB Initiative and should not be used for any other purpose.

Complete the information below and return the signed document to the CIRB Operations Office via Fax to (301) 560-6538 OR scan and email to [email protected]. Access via a user name and password will be given to the person named in line #1. Access will automatically expire 30 days from the day the Operations Office sends the user name and password.

1. Name: _____________________________

2. Role: IRB Contact
   Research Staff
   Other __________________

3. Telephone: _____________________________

4. Email: _____________________________

5. Institution Name: _________________________________________

6. Board Type: Adult Pediatric Both

7. Investigator’s Name: ___________________________________

8. Investigator’s Cooperative Group Affiliation(s):
   ACOSOG CALGB

COG ECOG

GOG NCCTG

NCIC CTG NSABP

RTOG SWOG

______________________________ _______________________