Form 3c CIRB Board Member Contact Information Form

OMB#: 0925 – 0625 Expiry Date: 1/31/2014

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.

Attachment 3C:

Board Member: CONTACT INFORMATION FORM

Member Information

Name :      

Title:      

Address:      

     

Work Phone:      

Cell Phone:      

Fax:      

Email:      

 Please check here if this is the address you prefer to receive hard copies of board materials

Personal Information (or to be used as alternate contact information)

Address:      

     

Home Phone:      

Cell Phone 2:      

Fax 2:      

Email 2:      

 Please check here if this is the address you prefer to receive hard copies of board materials

Alternate Contact (include if another person in your office should be cc’ed on correspondence)

Name :      

Title:      

Address:      

     

Phone:      

Fax:      

Email:      

Please return this form to the Operations office via email ([email protected]) or fax (301-560-6538).

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