Research Review Committee Documentation of Review and Approval
Request to Conduct Research at Facility
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Project Title: ___________________________ |
IRB No.: _________________________ |
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Submitted by: ____________________ |
Affiliation: _________________________ |
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Email: __________________________________ |
Tele: ________________________________ |
Primary Investigation (if different from person submitting): _______________________________________
Project Location(s): ____________________________________________________________________
Community Approval: __________________________________________________________________
Management Company Approval: _________________________________________________________
Funding Source(s): _____________________________________________________________________
Grant Title (if applicable and if different from project title): __________________________________
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Research to Include: |
____Cognitively Impaired |
____Economically or Educationally Disadvantaged |
____Others _______Specify |
Research Submission:
________ Informed consent, dated ________
________ Privacy notice
________ Drug or device brochure(s), dated ________
________ Protocol, include any questionnaire(s), dated ________
________ Summary Safety Guard Statement, dated ________
________ Advertisement (if applicable), dated ________
________ Authorization, dated ________
________ Other (description), dated ________
________ Consents
________ IRB approval letter
Please mail all materials to:
I assure the Research Review Committee (RRC) that all procedures performed under the project will be conducted in strict accordance with those federal regulations and internal policies that govern research involving human subjects. I agree to submit any deviation from the project in the form of an amendment for RRC approval prior to implementation. By signing this form, I am certifying that all co-investigators listed in the study are aware of the research and are agreeing to participate.
NOTE: Applications and any additional material requested by the RRC will not be processed unless neatly typed and legible, properly prepared, and signed personally by the principal investigator.
Date ____________________ Principal Investigator (Signature) _____________________________
******************************FOR RRC USE ONLY************************************
This protocol and informed consent statement for use of subjects in research has been reviewed and approved by the RRC for a maximum of a one-year period beyond the final approval date unless otherwise indicated as follows: _________________.
Authorized RRC Signature ________________________________________________________
RRC Approval Date ________________________________________________________
Recorded in the Minutes of: _________________________________________________________________________