N CI Pediatric CIRB
REVIEWER WORKSHEET
Amendment to Cooperative Group Protocol
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 2 hours 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.
STUDY ID:
STUDY TITLE:
NAME
OF CIRB REVIEWER:
DATE COMPLETED:
1. I have reviewed the following documents (check all that apply):
NCI Pediatric CIRB Application for Treatment Studies or NCI Adult/Pediatric CIRB Application for Ancillary Studies
Summary of CIRB Application Revisions
Summary of Changes related to the Amendment
Study Protocol
Cooperative Group Model Informed Consent Document(s)
Other (specify):
2. The amendment includes the following changes (check all that apply):
Increase or decrease in accrual (impacts statistical design)
Addition or deletion of a treatment group/arm
Addition or deletion of a study drug
Change in treatment period/treatment design
Changes in the informed consent document(s)
Editorial and/or administrative changes
Other:
3. Please provide a brief summary of the current approved protocol. (Note to reviewer: Not applicable for amendments containing solely editorial and/or administrative changes)
4. Please provide the rationale for the amendment. (Note to reviewer: Not applicable for amendments containing solely editorial and/or administrative changes)
5. Do the changes in the amendment alter the risk/benefit ratio to the participants?
If Yes, explain whether the benefits continue to outweigh the risks.:
No
If Uncertain, please explain:
6. Do any of the changes in this amendment include significant new findings that might relate to the participant’s willingness to continue participation in the research?
If Yes, describe what plans are included to notify/re-consent participants and indicate whether the plans are sufficient.:
If No, please explain:
7. Please provide your comments and/or concerns regarding the amendment.
8. Please provide your recommendation for CIRB action on the amendment.
Pediatric Risk Assessment
9. 45 CFR 46.404: Research no involving greater than minimal risk
Minimal Risk
Explanation based on study documentation:
Adequate provisions are made for soliciting the assent of the children and the permission of their parents or guardians, as set forth in 46.408.
Explanation based on the study documentation:
Permission required from
One Parent
Both Parents
10. 45
CFR 46.405: Research involving greater than minimal risk but
presenting the prospect of direct benefit to the individual
subjects
Greater
than minimal risk
Explanation
based on study documentation:
Prospect
for direct subject benefit
Explanation
based on study documentation:
The risk is justified by the anticipated benefit to the subjects
Explanation based on study documentation:
The
relation of the anticipated benefit to the risk is at least as
favorable to the subjects as that presented by available alternative
approaches
Explanation
based on study documentation:
Adequate
provisions are made for soliciting the assent of the children and
permission of their parents or guardians, as set forth in
46.408.
Explanation
based on study documentation:
Permission required from
One Parent
Both Parents
11. 45
CFR 46.406: Research involving greater than minimal risk and no
prospect of direct benefit to individual subjects, but likely to
yield generalizable knowledge about the subject's disorder or
condition
Greater
than minimal risk
Explanation
based on study documentation:
The
risk represents a minor increase over minimal risk
Explanation based on study documentation:
The
intervention or procedure presents experiences to subjects that are
reasonably commensurate with those inherent in their actual or
expected medical, dental, psychological, social, or educational
situations
Explanation
based on study documentation:
The
intervention or procedure is likely to yield generalizable knowledge
about the subjects' disorder or condition which is of vital
importance for the understanding or amelioration of the subjects'
disorder or condition
Explanation
based on study documentation:
Adequate
provisions are made for soliciting assent of the children and
permission of their parents or guardians, as set forth in 46.408.
Both parents will provide permission.
Explanation
based on study documentation:
12. 45
CFR 46.407: Research not otherwise approvable which presents an
opportunity to understand, prevent, or alleviate a serious problem
affecting the health or welfare of children
The
IRB does not believe meets the requirements of 46.404, 46.405,
46.406
Explanation based on study documentation:
The
IRB finds that the research presents a reasonable opportunity to
further the understanding, prevention, or alleviation of a serious
problem affecting the health or welfare of children
Explanation
based on study documentation:
13. 45 CFR 46.408: Requirements for assent by children
Assent requirement waived
Capability
of some or all of the children is so limited that they cannot
reasonably be consulted
OR
Procedure
involved in the research holds out a prospect of direct benefit that
is important to the health or well-being of the children AND the
intervention is available only in the context of the research
OR
Assent
may be waived in accord with 45 CFR 46.116
Explanation
based on study documentation:
Assent
required
Age where assent is expected. Standard age ranges
will be determined and provided as options.
Adapted from ePanel© 05/10/13
File Type | application/msword |
File Title | NCI PEDIATRIC |
Author | mmasciocchi |
Last Modified By | Deloris Miles |
File Modified | 2013-08-15 |
File Created | 2013-08-15 |