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NIOSH IRB-HSRB Continuing Review/Renewal Template_CDC 0.1379+0.1251+0.1370
0.1379

Centers for Disease Control and Prevention
NIOSH IRB (HSRB)

Signature Page for Human Research

Date Received:
06/30/2014 6/16/15 e
XXXXXXX
Review DTrout

Anniversary Date: 07/09/2015
__________
Use this signature page when submitting HRPO forms to your center-level Human Subjects
Contact. When submitting materials with these forms, please consecutively number all pages,
beginning with the protocol title page and followed by consent form(s) and ancillary documents. See HRPO Guide:
Overview for further details. NOTE: IRB (Institutional Review Board) refers to the NIOSH IRB-HSRB (National
Institute for Occupational Safety and Health (NIOSH), Human Subjects Review Board (HSRB) of the CDC Human
Research Protection Office (HRPO).

Protocols and Related Documentation

1

Protocol Identifiers

CAN#: _____________ (optional)

Leave protocol ID blank if not yet assigned.
CDC Protocol ID: HSRB __________________________
Protocol Version Number: ____
HSRB 11-DSHEFS-03XP
04/15/2014
2 Version Date: ____________
Protocol Title:
Evaluating the Effectiveness of Occupational Safety and Health Program Elements in the Wholesale Retail Trade Sector
___________________________________________________________________________________________________
Amendment Number (if applicable): _______

2

Key CDC Personnel
Name and Degrees

User ID

Primary Contact

__________________________
Steve Wurzelbacher, Ph.D
__________________________
513-841-4322

______
srw3

____________
4169

_________________
NIOSH/ DSHEFS

Principal Investigator

__________________________
Steve Wurzelbacher, Ph.D
__________________________
513-841-4322

______
srw3

____________
4169

_________________
NIOSH/ DSHEFS

(First Name Last Name, Degrees)

Phone Number (required)
Phone Number (required)

CDC SEV #

CDC NC/Division

SEV # is CDC’s Scientific Ethics Verification Number. CDC NC/Division is the national center or equivalent and division
or equivalent, or coordinating center or office if submitted at that level.

3

Forms Submitted with this Signature Page
Check all that apply in the appropriate column.
IRB-Reviewed Protocols

Exempted Protocols (All shaded will not apply here)

0.1250: Initial Review by IRB

0.1250X: Initial Review for Exemption

0.1251: Continuing Review of Approved Protocol

0.1251X: Continuing Review of Exempted Protocol

0.1252: Review of Changes to Approved Protocol

0.1252X: Review of Changes to Exempted Protocol

0.1254: Incident Report
0.1254S: Supplemental Adverse Event Report
0.1253: End of Human Research Review

0.1253: End of Human Research Review

0.1370: CDC’s Research Partners

0.1370: CDC’s Research Partners

0.1371: CDC Rely on a Non-CDC IRB
0.1372: Outside Institution Rely on a CDC IRB
0.1373: CDC Cover an Individual Investigator
CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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4

Signatures
As principal investigator, I hereby accept responsibility for conducting this CDC-sponsored research project in an ethical
manner, consistent with the policies and procedures contained in CDC's Procedures for Protection of Human Research
Participants, and to abide by the principles outlined in federal policies for the protection of human subjects at 45 CFR part
46, 21 CFR part 50, and 21 CFR part 56.
Signature
Date Signed
Remarks
Principal CDC Investigator:
____________
06/15/2015

Steven J. Wurzelbacher -S

Digitally signed by Steven J. Wurzelbacher -S
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1001263232, cn=Steven J. Wurzelbacher S
Date: 2015.06.15 10:46:20 -04'00'

__________________________________________________________

_______________________

As a supervisor of the principal investigator, I hereby accept responsibility for ensuring that this CDC-sponsored research
project is conducted in an ethical manner, consistent with the policies and procedures contained in CDC's Procedures for
Protection of Human Research Participants, and to abide by the principles outlined in federal policies for the protection of
human subjects at 45 CFR part 46, 21 CFR part 50, and 21 CFR part 56.
Signature
Date Signed
Remarks
PI is Team Lead
Team Lead:
____________
06/15/2015

Steven J. Wurzelbacher -S

Digitally signed by Steven J. Wurzelbacher -S
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1001263232, cn=Steven J. Wurzelbacher -S
Date: 2015.06.15 10:46:41 -04'00'

Branch Official (e.g., Chief or Senior Scientist):

Elizabeth A. Whelan -S3

Division Official (e.g., Director or ADS):
TROUT.DOUGLAS.B.1015465804

____________
06/15/2015

PI is Branch Official

____________
06/15/2015

PI is Division Official

Digitally signed by Elizabeth A. Whelan -S3
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1000272601, cn=Elizabeth A. Whelan -S3
Date: 2015.06.15 10:52:44 -04'00'

Digitally signed by TROUT.DOUGLAS.B.1015465804
DN: c=US, o=U.S. Government, ou=DoD, ou=PKI, ou=USPHS,
cn=TROUT.DOUGLAS.B.1015465804
Date: 2015.06.15 12:25:48 -04'00'

I concur that this CDC-sponsored research project is consistent with the policies and procedures contained in CDC's
Procedures for Protection of Human Research Participants and with other applicable CDC and national center policies.
Signature For Co-Chair Gail McConnell
Date Signed
Remarks
/Chair NIOSH IRB-HSRB:
____________
07/09/2015
Contact with participants

Diane C. Morris -S
Other Clearance Official:

Digitally signed by Diane C. Morris -S
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1000059265, cn=Diane C. Morris -S
Date: 2015.07.09 09:56:47 -04'00'

continues. Consent
included.

____________

(e.g., Confidentiality Officer, Coordinating Center/Office Official)

THIS SECTION FOR CDC/NIOSH IRB-HSRB OFFICE USE ONLY:
Expedited Review
; Minimal Risk
; as provided for in 45CFR46.110.
(b) (1) category(s) _____________________________________________________
5, 7
Approved Review
for one year; Renewal Date: __________
07/09/2016
CDC 0.1250 cites Estimated Subject # is ___________
Subject # to Date is ___________
30000
255
Approved/Amended Subject # is ___________
30000
COMMENTS: _______________________________________________________
Full/Convened Board Review Approved
Meeting Date Approval: __________

5

Additional Comments
___________________________________________________________________________________________________

6

Reminder Regarding Other Regulatory Clearance Processes
The principal investigator is responsible for obtaining other regulatory reviews as needed, which may include OMB
clearance under the Paperwork Reduction Act (PRA) for federally sponsored information collections. Approval by or
exemption from the IRB is unrelated to OMB clearance requirements under the PRA. For more information on whether your
study requires clearance under PRA or other regulations, please consult the appropriate officials within your national center.
CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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NIOSH IRB-HSRB Continuing Review/Renewal Template_CDC 0.1379+0.1251+0.1370
0.1251 Centers for Disease Control and Prevention

Request for Continuing Review of
IRB-Approved Protocol
Use this form to submit a protocol for continuing review by a CDC IRB (Ex. NIOSH IRB-HSRB)
or a non-CDC IRB. [See 45 CFR 46.109(e).] See HRPO Guide: IRB Review Cycle for further
details on how to complete this form.

1

Protocol Identifiers
HSRB 11-DSHEFS-03XP
CDC Protocol ID: HSRB __________________________
Protocol Version Number: ____
04/15/2014
2 Version Date: ____________
Protocol Title:
Evaluating the Effectiveness of Occupational Safety and Health Program Elements in the Wholesale Retail Trade Sector
___________________________________________________________________________________________________

2

Key CDC Personnel
No change in key CDC personnel. When checked or not, please cite all CDC and NIOSH investigators.
Name and Degrees

User ID

Primary Contact

__________________________
Steve Wurzelbacher, Ph.D

______
srw3

____________
4169

_________________
NIOSH/ DSHEFS

Principal Investigator

__________________________
Steve Wurzelbacher, Ph.D

______
srw3

____________
4169

_________________
NIOSH/ DSHEFS

Investigator 2

__________________________
Alysha Meyers, Ph.D.

______
ITM4

____________
15452

_________________
NIOSH/ DSHEFS

Investigator 3

__________________________
Jennifer Bell, Ph.D.

______
zvd4

____________
7500

_________________
NIOSH/ DSR

Investigator 4

__________________________
Kaori Fujishiro, Ph.D

______
fnd3

____________
1765

_________________
NIOSH/ DSHEFS

Investigator 5

__________________________
Steve Bertke, Ph.D

______
INH4

____________
6664

_________________
NIOSH/ DSHEFS

(First Name Last Name, Degrees)

(required)
(required)

CDC SEV #

CDC NC/Division

SEV # is CDC’s Scientific Ethics Verification Number. CDC NC/Division is the national center (or equivalent) and division
(or equivalent), or coordinating center or office if submitted at that level.
Continue list here of all other CDC and NIOSH investigators, if any. Include name and degrees, user ID, CDC SEV #,
CDC NC/Division:
Tim Bushnell, plb4, 12294, NIOSH-DSHEFS; Chih-Yu Tseng, cft8, SEV# 16085, NIOSH-DSHEFS; Chia Wei, PhD,
ycj4, SEV# 10300,
___________________________________________________________________________________________________

3

CDC’s Research Partners
Research partners include all direct and indirect recipients of CDC funding (e.g., grants, cooperative agreements, contracts,
subcontracts, purchase orders) and other CDC support (e.g., identifiable private information, supplies, products, drugs, or
other tangible support) for this research activity, as well as collaborators who do not receive such support. On continuing
review, HRPO needs current information on partners that have been added or dropped since the last review and partners
that, as of the last review, were receiving support for nonexempt research. See HRPO Guide: CDC’s Research Partners for
further details.
All CDC partners must be listed on form CDC 0.1370.
Check one of the following.
No research partners are reported with this submission. (Checked when there are no non-CDC partners.)
Research partners (non-CDC) are listed on form CDC 0.1370, which accompanies this form.
CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
Page 3 of 12
HSRB 11-DSHEFS-03XP
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4

Study Participants—Cumulative Demographic Frequencies
Have any participants been enrolled in the last 12 months?
Yes
No (If no, still report total subject # to date.)
Report estimated counts (rather than percentages). Include participants at domestic and foreign sites. [Note: All subcategory totals should be equal; total subject numbers are counted from beginning of study conduct until the date
completing this form. See also HRPO Guide: IRB Review Cycle for definitions.]
Number of Participants
__________
255 __
Location of Participants
Participating at Domestic Sites
Participating at Foreign Sites

________
255 ____
____________

Sex/Gender of Participants
Female
Male
Sex/Gender Not Available

____________
____________
________
255 ____

Ethnicity of Participants
Hispanic or Latino
Not Hispanic or Latino
Ethnicity Not Available

____________
____________
________
255 ____

Race of Participants
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More Than One Race
Race Not Available

____________
____________
____________
____________
____________
____________
________
255 ____

CDC Form 0.1250 initial review, #5 cited 30,000 number estimated subjects. To exceed subject # cited on CDC
0.1250, an amendment request (CDC forms 0.1252+ 0.1379) needs to be completed/submitted to the NIOSH IRB-HSRB for
review/approval. Comments on Demographics:
Evaluating the Effectiveness of Occupational Safety and Health Program Elements in the Wholesale Retail Trade Sector
___________________________________________________________________________________________________

5

Study Status—Participant Involvement

5.1 Contact Status
“Contact” means intervention or interaction with participants, such as recruitment, screening, obtaining consent,
enrollment, and collection of data and biological specimens directly from participants. Check one of the following.
Study is not designed to involve research-related contact with participants (e.g., research using existing records); study
activities involve only access to or analysis of data or biological specimens and writing reports.
Study is designed to involve contact with participants. Check one of the following:
Contact with participants has not yet begun. (If checked, include a cc current consent with submission.)
Contact with participants has begun and continues; this may include follow-up for debriefing or notification of
results. (If checked, include a cc current consent with submission.)
Contact with participants is completed; study activities involve only data analysis or report writing.

CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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5.2 Consent Status
“Consent” includes adult consent, child assent, and parental permission. Check one of the following.
The IRB previously waived all requirements both to obtain and to document consent in this study.
Although not waived, there is no further need to obtain or document consent (e.g., enrollment is complete).
Participants will be asked to provide consent (with or without documentation).
If you check the third box, please include all current consent, assent, and parental permission materials (e.g., scripts,
documents) from each study site with this submission.

6

Study Status—Overall Conduct [Please complete all summaries.]
Summary of research activities to date. Briefly summarize study progress and interim findings. Include the number of
potential subjects who declined enrollment and the number who withdrew from the study. If this study involves a registrable
clinical trial, summarize registration status. [Citing “none” for this summary is incomplete.]

As of 6/15/15, there are 255 participants.
___________________________________________________________________________________________________
Summary of study changes reviewed and approved since the last continuation. Do not include changes submitted with or
before approval of this continuation but not yet approved.

Continue

There are no study changes since last approval.
___________________________________________________________________________________________________
Summary of any recent literature or other information relevant to the research study (not limited to information with CDC
co-authorship).

Continue

See continuation on page 11.
___________________________________________________________________________________________________
Summary of all adverse events to date. In particular, address adverse events that were serious, unexpected (or more frequent
or severe than expected), or at least possibly related to the research.

Continue

There have been no adverse events.
___________________________________________________________________________________________________
Summary of (a) incidents that are not adverse events and (b) other substantial concerns since last continuation.

Continue

There have been no incidents or substantial concerns.
___________________________________________________________________________________________________
List and include copies of progress or monitoring reports on safety or compliance (e.g., site monitor, safety review, DSM
report, multi-center trial report, but not reports to PGO).

Continue

There are no safety or compliance reports to list.
___________________________________________________________________________________________________
Summary of remaining research activities, emphasizing future contact with subjects, use of identifiable private data and
biological specimens, and preparation of primary reports. [Citing “none” for this summary is incomplete.]

NIOSH will continue to collect 2nd year and nested surveys according to the protocol (version date 04/15/2014)
___________________________________________________________________________________________________
CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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7

Regulation and Policy

7.1 Mode of IRB Review on CDC’s Behalf
Location of IRB (Check one.):
CDC IRB (Ex. NIOSH IRB/HSRB)
Non-CDC IRB through IRB Authorization Agreement [Submit form CDC 0.1371 if this is a new request.]
Institution or Organization Providing IRB Review: ___________________________________________________
IRB Registration Number (if known): _______________
Federal-Wide Assurance Number (if any): _______________
IRB-Determined Level of Risk to Subjects (Check one.):
Minimal
Greater than Minimal
Suggested Level of IRB Review (Check one.):
See HRPO Worksheet for Expedited Review for detailed assistance. If relying on a non-CDC IRB, please indicate the level
of review that you think is appropriate under human research regulations.
Convened-board review is suggested.
Reason for Convened Review: ___________________________________________________________________
Expedited review is suggested, under the following categories (Check all that apply.):
1a Study of drugs not requiring Investigational New Drug exemption from FDA
1b Study of medical devices not requiring Investigational Device Exemption from FDA
2a Collection of blood from healthy, nonpregnant adults; below volume limit, minimally invasive
2b Collection of blood from other adults and children; below volume limit, minimally invasive
3
Prospective noninvasive collection of biological specimens for research purposes
4
Collection of data through routine, noninvasive procedures, involving no general anesthesia, sedation, xrays, or microwaves
5
Research that uses materials collected solely for nonresearch purposes
6
Collection of data from voice, video, digital, or image recordings made for research purposes
7
Research that uses interview, program evaluation, human factors, or quality assurance methods
Continuing review of research previously approved by the convened IRB (8a, 8b, 8c, or 9) where:
8a The research is permanently closed to the enrollment of new subjects; all subjects have
completed all research-related interventions; and the research remains active only for long-term
follow-up of subjects
8b No subjects have been enrolled and no additional risks have been identified
8c The remaining research activities are limited to data analysis
9
Continuing review of research, not under IND/IDE, where categories 2 through 8 do not apply but the IRB
has determined and documented at a convened meeting that the research involves no greater than minimal
risk and no additional risks have been identified

CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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8

Material Submitted with this Form
Check all that apply. Describe additional material in the comments section. Required items are indicated. Optional items
may be requested by HRPO or the IRB.
Complete protocol (required if research poses more than minimal risk to subjects, is under IND/IDE, or has changed in
the past 12 months)
Consent, assent, and permission documents or scripts (required if consent will be sought in the future from prospective
subjects or their representatives [see section 5.2])
Other information for recruits or participants (e.g., ads, brochures, flyers, scripts; required if consent will be sought in the
future from prospective subjects or their representatives)
Data collection instruments (e.g., questionnaires, interview scripts, record abstraction tools; required if protocol has
changes in the past 12 months)
Certification of IRB approval or exemption for research partners (required only for partners being added or for
supported/nonexempt partners)
Progress and monitoring reports (recommended when available)

9

Additional Comments (Cover Memo content can go here.)
See attached protocol (version date 04/15/2014), including consent forms. Only consent included. DCMorris

___________________________________________________________________________________________________
CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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0.1370 Centers for Disease Control and Prevention

CDC’s Research Partners
Use this form to report current information on CDC’s research partners whenever a partner
institution or individual is added or information changes. Supply individual name and completed
ethics training documentation only for investigators collaborating with CDC under an individual
investigator agreement (IIA). See HRPO Guide: CDC’s Research Partners and either the HRPO
Worksheet for Basic Tracking of Research Partners or the HRPO Worksheet for Advanced
Tracking of Research Partners for details on how to complete this form.
Leave protocol ID blank if not yet assigned.
HSRB 11-DSHEFS-03XP
CDC Protocol ID: HSRB __________________________
Protocol Version Number: ____
04/15/2014
2 Version Date: ____________
Protocol Title:
Evaluating the Effectiveness of Occupational Safety and Health Program Elements in the Wholesale Retail Trade Sector
___________________________________________________________________________________________________
NOTE: Each partner below reflects either a non-CDC Institution or non-CDC Individual so all fields cannot be
completed. At minimum, please provide the name of the Institution/Individual; their City/State; and briefly cite in the
Comments field their role in this research (what they will do) and include your estimate of engaged or not. Engaged means
either to: 1) interact/intervene with subjects; or 2) access private/identifiable information; or 3) receive federal funds.

Partner 1

Partner 2

Ohio Bureau of Workers Compensation
Institution Name: _________________________________
Columbus, OH
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Previously Reported
Regulatory Coverage: _____________________________
Engaged/Non-Exempt
Financial Support: ________________________________
Contract/Subcontract
214-2011-M-40781; 214-2011Support Award Number: ___________________________
Support End Date: ____________
09/30/2015
Nonfinancial Support: _____________________________
Identifiable Private Information
FWA Number: ___________________________________
00017192
SEV Number (IIA only): __________
IRB Review Status: _______________________________
Relying On CDC IRB
06/30/2015
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

Institution Name: _________________________________
U of Texas School of Public Health
Institution Location: _______________________________
Houston, TX
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Previously Reported
Regulatory Coverage: _____________________________
Engaged/Non-Exempt
Financial Support: Contract/Subcontract
________________________________
Support Award Number: ___________________________
200-2011-39475 00004
Support End Date: 09/30/2015
____________
Nonfinancial Support: _____________________________
No Nonfinancial Support
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
Review By Local IRB
IRB Approval Expiration Date: ____________
04/11/2016
Comments (Their Role in this Research):

1372A on file 5/11/2011. DCMorris

Need current IRB approval. DCMorris

________________________________________________

________________________________________________

CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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Partner 3

Partner 4

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

________________________________________________

________________________________________________

Partner 5

Partner 6

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

________________________________________________

________________________________________________

CDC 0.1379 (E), Revised December 2013, CDC Adobe Acrobat 10.1, S508 Electronic Version, June 2014
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HSRB 11-DSHEFS-03XP
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Partner 7

Partner 8

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

________________________________________________

________________________________________________

Partner 9

Partner 10

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

Institution Name: _________________________________
Institution Location: _______________________________
Individual Name (IIA only): ________________________
Reporting Status: _________________________________
Regulatory Coverage: _____________________________
Financial Support: ________________________________
Support Award Number: ___________________________
Support End Date: ____________
Nonfinancial Support: _____________________________
FWA Number: ___________________________________
SEV Number (IIA only): __________
IRB Review Status: _______________________________
IRB Approval Expiration Date: ____________
Comments (Their Role in this Research):

________________________________________________

________________________________________________

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1251 6.3 Summary of Relevant Recent Literature: There has been one intervention effectiveness analysis involving OBWC
workers compensation data recently published or in press:
Wurzelbacher SJ, Bertke SJ, Lampl ML, Bushnell T, Meyers AM, Robins D, Tarawneh A. The effectiveness of
insurer-supported safety and health engineering controls in reducing workers' compensation claims and costs. Am J Ind
Med. 2014 Dec;57(12):1398-412. doi: 10.1002/ajim.22372. Epub 2014 Sep 15.
(http://www.ncbi.nlm.nih.gov/pubmed/25223846)

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