Form 13 Add or Remove Component Institution

Add or Remove Component Institution

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 Component Institution(s)

Provide information below to remove Component Institution(s). The CIRB will no longer be the IRB of record for these Component Institution(s).
Component Institution Name	NCI Institution Code
     	     
     	     
     	     

Add New Component Institution(s)

Component Institutions are defined by the CIRB as meeting ALL of the following criteria: the Component Institution operates under a different name than the Signatory Institution, but the Signatory Institution has legal authority for the Component Institution; the FWA number for the Component Institution is the same as the Signatory Institution; the local context considerations of the Component Institution are the same as the Signatory Institution. Local context considerations are reported by the Signatory Institution in the Annual Institution Worksheet About Local Context; the boilerplate language and institutional requirements of the Component Institution are the same as the Signatory Institution. The boilerplate language and institutional requirements are reported by the Signatory Institution in the Annual Institution Worksheet About Local Context; and the conduct of research at the Component Institution is monitored by the same office as the Signatory Institution Provide the information requested for each Component Institution that meet the CIRB’s definition.
Add Revise
Signatory Institution Name      
Component Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

Add Revise
Signatory Institution Name      
Component Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

Add Revise
Signatory Institution Name      
Component Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

Add Revise
Signatory Institution Name      
Component Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

Add Revise
Signatory Institution Name      
Component Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

Add Revise
Signatory Institution Name      
Component Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

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