Form 49 CIRB App for Translated Docs

CIRB APPLICATION FOR TRANSLATED DOCUMENTS

OMB #0925-xxxx Expiration Date: xx/xx/xxxx
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 30 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-xxxx*). Do not return the completed form to this address.

Complete and submit this form to request CIRB review of translated documents. If you
have any questions regarding the completion of this request, please contact the CIRB
Helpdesk at 888-657-3711 or [email protected].
In order for the CIRB to review and approve translated documents, the English language
version of the document must already have CIRB approval.
STUDY NUMBER:
STUDY TITLE:
PROTOCOL VERSION DATE:
This request should be based on the current CIRB-approved Protocol Version Date.
STUDY CHAIR:
The Study Chair requests CIRB review and approval of the following translated documents.
Please check all that apply:
Informed Consent Document (ICD). If submitting multiple ICDs, please list titles
below:
1.
2.
Other documents (please list below):
1.
Application version dated 07/12/11_update date 01/28/14

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2.

Additional Required Documents. Check off below when document is attached:
CIRB-approved English language document(s) corresponding to the translated
document
Translated version(s) of the CIRB-approved English language document
Translator’s Certificate(s) of Accuracy or equivalent document(s)

Application version dated 07/12/11_update date 01/28/14

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