Form 82 Board member application

APPLICATION FOR NCI CIRB MEMBERSHIP
OMB #xxxx-xxxx, Expiration
ExpirationDate:
Date:xx/xx/xxxx
06/30/2020

Atttachment_B03_NCI_CIRB_Membership
OMB#0925-0753

The purpose of the information collection is to conduct reviews of clinical trial studies. NCI guidelines mandate the participation of institutions in
the CIRB for Network group studies. You are being requested to complete this instrument so that we can conduct activities involved with the
operations of the NCI CIRB Initiative. Although your participation in Network group research and completion of the forms is voluntary, if you
wish to participate in the CIRB, you must complete all questions on the form. The information you provide will be combined for all participants
and reported as summaries. It will be kept private to the extent provided by law.
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 (0925-0753). Do not return the completed form to this address.

INSTRUCTIONS
Before completing this application please review the following materials:
1. CIRB MEMBERSHIP BASICS
The role and expectations of CIRB members are described in the section CIRB Membership
Basics on the website. An applicant does not need to have all of the knowledge, skills, and
experience outlined in this section, however, applicants who are selected to serve on the
CIRB will have demonstrated in their application and supporting materials how their
experience and qualifications are suited to the role of CIRB member.
2. CONFLICT OF INTEREST (COI) WORKSHEET
Consider reviewing the CIRB Member CoI worksheet before you begin the application
process. On occasion an applicant may be too conflicted to serve on the CIRB or their
potential conflicts of interest may result in frequent recusal which cannot be managed. NCI
employees and contractors are not eligible to serve on the CIRB. As part of this application,
you will be asked to complete and submit the CoI screening worksheet.
TO APPLY:
1. Complete this application and the CoI Screening worksheet.
2. Email the completed application, CoI Screening worksheet, and your resume, CV, or Bio to
[email protected] with ‘CIRB Member Application’ in the subject line.
3. If you have questions regarding the application process or materials, contact the NCI CIRB
Helpdesk at [email protected] or call 1-888-657-3711.

APPLICATION FOR NCI CIRB MEMBERSHIP

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1. APPLICANT INFORMATION
Name:
Institution:
Phone Number:
Email Address:
Mailing Address:
Please indicate which CIRB you are interested in serving on—you may select more than one or
indicate that you do not have a preference:
Adult CIRB – Late Phase Emphasis
Adult CIRB – Early Phase Emphasis
Pediatric CIRB
Cancer Prevention and Control CIRB
I do not have a preference
2. SUMMARY OF QUALIFICATIONS
How will your qualifications and experience contribute to the CIRB?
3. MEMBER DIVERSITY
The NCI CIRBs review research that impacts thousands of people who represent a variety of
communities, backgrounds, and ethnicities. The CIRB strives to ensure representation of these
people and communities by selecting board members’ whose experience, expertise, and cultural
background contribute to the diversity of the CIRB. Diversity can also be found in the
geographic locations of CIRB members, the communities they serve, as well as more traditional
notions of diversity such as race and gender.
How would your experiences contribute to the diversity of perspectives represented on the
CIRB?
4. REFERENCES
List the names and contact information of two (2) individuals who can speak to your experience
and qualifications to serve on the CIRB.
REFERENCE 1
Name
Relationship
Institution
Phone Number
Email

APPLICATION FOR NCI CIRB MEMBERSHIP

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REFERENCE 2
Name
Relationship
Institution
Phone Number
Email
6. CHECKLIST FOR SUBMISSION
Application for NCI CIRB Membership;
CV, Resume, or Bio;
CoI Screening worksheet.
NOTE: Please submit documents attached to a single email. Please do not send three separate emails.
Thank you!
WHAT NEXT?
Once you have submitted the above documents, you will receive a confirmation email within 48 hours.
You will then be contacted within a month after the close date for applications, regarding the status of
your application.

Posted: June 15, 2017

APPLICATION FOR NCI CIRB MEMBERSHIP

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