Form 14 Add or Remove Affiliate Institution

Add or Remove Affiliate 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 Affiliate Institution(s)

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

Add New Affiliate Institution Information

Affiliate Institutions are defined by the CIRB as meeting ALL of the following criteria: the local context considerations of the Affiliate 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 Affiliate 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 Affiliate Institution is monitored by the same office as the Signatory Institution. Provide the information requested for each Affiliate Institution that meets the CIRB’s definition and provide contact information for Sub-Investigators and Research Staff for each Affiliate Institution.
Signatory Institution Name      
Affiliate Institution Name      
FWA Number      	NCI Institution Code      
Is this Institution an NCI-designated Cancer Center? (Yes, No)

Sub-Investigator Information Sub-Investigators are physician investigators who have a significant 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 will receive access to the CIRB website. Provide the contact information for each Sub-Investigator located at the new Affiliate Institution named on page one. Sub-Investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      

Sub-Investigator Information
First Name      	Last Name      		Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Sub-Investigators from this new Affiliate Institution, access the Add or Remove Affiliate Institution Personnel form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it to the CIRB Operations Office at [email protected].

Research Staff Information Provide contact information for Research Staff from the new Affiliate Institution named on page one 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. Research Staff will receive access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Research Staff from this Affiliate Institution, access the Add or Remove Affiliate Institution Personnel form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it to the CIRB Operations Office at [email protected].

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