Form 16 Change of Signatory Institution PI Form

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.

Change of Signatory Institution Principal Investigator Form

Complete and submit this form to request a change of the Principal Investigator on a study currently open at the Signatory Institution.

Important note: The new PI must have an Annual Principal Investigator Worksheet About Local Context and a Study-Specific Worksheet About Local Context for this study on file at the CIRB Operations Office before the change of a Signatory Institution Principal Investigator can be approved.

1. Name of the Person from the Signatory Institution Completing the Form     

2. Signatory Institution Name:      

3. Study Number:      

4. Study Title:      

5. Current Principal Investigator Name:      

6. Enter the email address of the new Signatory Institution Principal Investigator for this study:      

7. New Principal Investigator Name:      

8. Has the New Principal Investigator submitted an Annual Principal Investigator Worksheet About Local Context? Yes No

If no, must submit before change can be CIRB-approved.

9. Has the New Principal Investigator submitted a Study-Specific Worksheet About Local Context for this study? Yes No

If no, must submit before change can be CIRB-approved.

Once the CIRB has received and reviewed all required documents, you will receive a letter from the CIRB regarding the Change of Signatory Institution Principal Investigator Form.

If you have any questions regarding the completion of this request, please contact the CIRB Helpdesk at 888-657-3711 or [email protected].

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