Form 2x Add or Remove Affiliate Institution Personnel

Add or Remove Affiliate Institution Personnel

This form must be submitted by the Signatory Institution Primary Contact.

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.

Remove Affiliate Institution Personnel

Provide information below to remove personnel from Affiliate Institution(s). These individuals will no longer have access to the CIRB website or receive study-related correspondence from the CIRB.
First Name	Last Name	NCI Investigator Number / NCI Person ID Number	Role of Person
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     

Add New Affiliate Institution Personnel Information

Provide the information requested for new or existing personnel at the Affiliate Institutions including: Sub-Investigators and Research Staff.

Sub-Investigators and Research Staff are those who have a role in the conduct of studies opened using the CIRB and function under the direction of a specific study’s Signatory Institution Principal Investigator. Sub-Investigators and Research Staff will receive access to the CIRB website.

New personnel will receive information about how to access the CIRB Website in a separate email.

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

Add Revise
Signatory Institution Name      
Affiliate Institution Name      
Role of Person at Affiliate Institution (Sub-Investigator, Research Staff)
First Name      	Last Name      		Degree      
Title/Role (for Research Staff only)      
NCI Investigator Number / NCI Person ID Number      		Email Address      
Telephone Number (   )   -    		Extension      

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