Form 2 NCI CIRB Institution Enrollment Worksheet

NIH NCI Central Institutional Review Board (CIRB) Initiative (NCI)

Attachment 2A - NCI CIRB Enrollment Form_110110

NCI CIRB Institution Enrollment Worksheet (Attach 2A)

OMB: 0925-0625

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0625 can be found here:

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National Cancer Institute
Central IRB Initiative
CIRB Operations Office
c/o: The EMMES Corporation
401 N. Washington St. Suite 700
Rockville, MD 20850
Tel: 1 -888-657-3711 (Toll Free)
Fax: 301-560-6538
E-mail: ncicirbcontact@emmes.com

Attachment 2:
NCI CIRB INSTITUTION ENROLLMENT WORKSHEET
The NCI CIRB Institution Enrollment Worksheet is a form-based Microsoft Word document that must be completed
electronically. Once the worksheet is completed,please email it to the CIRB Operations Office at
ncicirbcontact@emmes.com.
SECTION A: INFORMATION ABOUT THE ENROLLING INSTITUTION

•

INSTITUTION INFORMATION.............................................................................................................................................................2

•

IRB INFORMATION...................................................................................................................................................................................3

•

INVESTIGATOR INFORMATION ......................................................................................................................................................10

•

RESEARCH STAFF INFORMATION.................................................................................................................................................16

•

INFO RMATION ABOUT INSTITUTIONS IDENTIFIED ON YOUR FEDERAL WIDE ASSURANCE (FWA) AS
‘INSTITUTIONAL COMPONENTS’...................................................................................................................................................19

SECTION B : INFORMATION ABOUT IRBS AT OTHER INSTITUTIONS WHO HAVE DESIGNATED AN IRB AT
YOUR INSTITUTION ON THEIR FEDERAL WIDE ASSURANCE (FWA) .................................................................................20
SECTION C: INFORMATION ABOUT INSTITUTIONS WITHOUT IRBS WHO HAVE DESIGNATED AN IRB AT
YOUR INSTITUTION ON THEIR FEDERALWIDE ASSURANCE (FWA) ..................................................................................35

OMB#: 0925 – xxxx

Expiry Date: xx/xx/xxxx

STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized under 42 USC 285a. While your participation is completely voluntary, to
participate in the NCI CIRB, completion of this form is required. Data collected as part of the NCI CIRB review is private
and protected by law. Under the provisions of Section 301d of the Public Health Service Act, no information that could
permit identification of a participating individual may be released. All such information will be kept private under the
Privacy Act and will be presented only in statistical or summary form.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to vary from 3 to 4 hours 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.

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Section A: Institution Information
(Institution of Signatory Official who signs the Authorization Agreement)
Institution Name
Street Address
Street Address #2
City

State

Zip

OHRP Federal Wide Assurance (FWA) Number
NCI Institution Code
Is this Institution a participating member of a Community Clinical
Oncology Program (CCOP)? Yes/No
Is this Institution a participating member of a Minority-Based
Community Clinical Oncology Program (MBCCOP)? Yes/No
Is this Institution an NCI-designated Cancer Center? Yes/No

Name of CCOP
Name of MBCCOP

Primary person completing this worksheet who would be the Institution’s Point of Contact
Institution Point of Contact Name
Title/Role
Telephone Number (

First

Last

Email Address
)

Extension

Institution GUID (Internal Use Only)

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Directions for Completing Section A: IRB Information
1.

List the IRB(s) at your institution that currently review Pediatric and/or Adult Cooperative Group cancer
treatment studies.
• Multiple pages are provided to accommodate institutions with more than one IRB conducting reviews of
these studies.
• If your institution has more than 6 IRBs reviewing Cooperative Group trials, please email the CIRB Help
Desk at ncicirbcontact@emmes.com for the appropriate worksheet.

Supply the OHRP IRB Registration Number for each IRB.

Indicate whether each IRB will be reviewing Adult or Pediatric Cooperative Group treatment studies or both.

Indicate whether or not each IRB will have the authority to accept the reviews of the CIRB by performing a
facilitated review.

For those IRBs with authority to perform a facilitated review, indicate the staff member with the responsibility
to report the use of facilitated review. (Reporting is done via the CIRB website).

For each IRB, enter address information as well as contact information for the IRB Chair, IRB
Director/Administrator, IRB Contact, and any other IRB Staff Member(s).

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NCI CIRB Institution Enrollment Worksheet
Section A: IRB Information

IRB # 1
IRB Name
OHRP IRB Registration Number
Review Type (Adult, Pediatric, Both)
Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical
Name of CCOP
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
Name of CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Name of MBCCOP
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP Name of MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Name of Cancer Center
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
Name of College, University, or Medical School
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
For IRBs with authority to perform facilitated review, provide name of person re sponsible for reporting the FR:
Reporting Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Chair Information
Chair Name
First
Last
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Director/Administrator Information
IRB Director/Administrator Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Contact Information (Primary Point of Contact for all CIRB Correspondence)
IRB Contact Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
Additional IRB Staff Member Information
IRB Staff Member Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip

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NCI CIRB Institution Enrollment Worksheet
Section A: IRB Information

IRB # 2
IRB Name
OHRP IRB Registration Number
Review Type (Adult, Pediatric, Both)
Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical
Name of CCOP
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
Name of CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Name of MBCCOP
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP Name of MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Name of Cancer Center
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
Name of College, University, or Medical School
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
For IRBs with authority to perform facilitated review, provide name of person responsible for reporting the FR:
Reporting Person Name
First
Last
Title
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Chair Information
Chair Name
First
Last
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Director/Administrator Information
IRB Director/Administrator Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Contact Information (Primary Point of Contact for all CIRB Correspondence)
IRB Contact Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
Additional IRB Staff Member Information
IRB Staff Member Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip

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NCI CIRB Institution Enrollment Worksheet
Section A: IRB Information

IRB # 3
IRB Name
OHRP IRB Registration Number
Review Type (Adult, Pediatric, Both)
Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical
Name of CCOP
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
Name of CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Name of MBCCOP
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP Name of MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Name of Cancer Center
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
Name of College, University, or Medical School
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
For IRBs with authority to perform facilitated review, provide name of person responsible for reporting the FR:
Reporting Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Chair Information
Chair Name
First
Last
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Director/Administrator Information
IRB Director/Administrator Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Contact Information (Primary Point of Contact for all CIRB Correspondence)
IRB Contact Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
Additional IRB Staff Member Information
IRB Staff Member Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip

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NCI CIRB Institution Enrollment Worksheet
Section A: IRB Information

IRB # 4
IRB Name
OHRP IRB Registration Number
Review Type (Adult, Pediatric, Both)
Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical
Name of CCOP
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
Name of CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Name of MBCCOP
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP Name of MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Name of Cancer Center
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
Name of College, University, or Medical School
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
For IRBs with authority to perform facilitated review, provide name of person responsible for reporting the FR:
Reporting Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Chair Information
Chair Name
First
Last
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Director/Administrator Information
IRB Director/Administrator Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Contact Information (Primary Point of Contact for all CIRB Correspondence)
IRB Contact Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
Additional IRB Staff Member Information
IRB Staff Member Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip

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NCI CIRB Institution Enrollment Worksheet
Section A: IRB Information

IRB # 5
IRB Name
OHRP IRB Registration Number
Review Type (Adult, Pediatric, Both)
Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical
Name of CCOP
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
Name of CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Name of MBCCOP
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP Name of MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Name of Cancer Center
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
Name of College, University, or Medical School
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
For IRBs with authority to perform facilitated review, provide name of person responsible for reporting the FR:
Reporting Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Chair Information
Chair Name
First
Last
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Director/Administrator Information
IRB Director/Administrator Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Contact Information (Primary Point of Contact for all CIRB Correspondence)
IRB Contact Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
Additional IRB Staff Member Information
IRB Staff Member Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip

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NCI CIRB Institution Enrollment Worksheet
Section A: IRB Information

IRB # 6
IRB Name
OHRP IRB Registration Number
Review Type (Adult, Pediatric, Both)
Will this IRB have authority to perform facilitated review? (Yes, No)
Is this IRB the IRB of Record for an entire Community Clinical
Name of CCOP
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
Name of CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Name of MBCCOP
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP Name of MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Name of Cancer Center
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
Name of College, University, or Medical School
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
For IRBs with authority to perform facilitated review, provide name of person responsible for reporting the FR:
Reporting Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Chair Information
Chair Name
First
Last
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Director/Administrator Information
IRB Director/Administrator Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
IRB Contact Information (Primary Point of Contact for all CIRB Correspondence)
IRB Contact Person Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip
Additional IRB Staff Member Information
IRB Staff Member Name
First
Last
Title/Role
Email Address
Telephone Number (
)
Extension
Street Address
Street Address #2
City
State
Zip

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Section A: Investigator Information
Please provide the CIRB with contact information for Investigators from your Institution who should receive study-related
correspondence from the CIRB. All Investigators will receive access to the Participant’s Area of the CIRB website
(www.ncicirb.org). Access to the Participant’s Area is necessary for IRB and Research Staff to view and download studyrelated documents to use during facilitated review or to save in the regulatory file. User names and passwords for the
Participant’s Area of the Website will be sent via email.

1. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG
, CALGB , COG
, ECOG , GOG , NCCTG
, NCIC CTG
, NSABP , RTOG
, SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

2. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG
,GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

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NCI CIRB Institution Enrollment Worksheet
Section A: Investigator Information

3. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

4. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

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)

NCI CIRB Institution Enrollment Worksheet
Section A: Investigator Information

5. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

6. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

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)

NCI CIRB Institution Enrollment Worksheet
Section A: Investigator Information

7. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

8. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

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)

NCI CIRB Institution Enrollment Worksheet
Section A: Investigator Information

9. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

10. Investigator Information
Investigator Name First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

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)

NCI CIRB Institution Enrollment Worksheet
Section A: Investigator Information

11. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

12. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (
)
Extension

)

Street Address
Street Address #2
City

State

Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
All Investigators from your Institution involved in Cooperative Group trials should be listed. If you need to add more
Investigators, please email the CIRB Help Desk at ncicirbcontact@emmes.com for the appropriate form.

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NCI CIRB Institution Enrollment Worksheet

Section A: Research Staff Information
Please provide the CIRB with contact information for Research Staff from your Institution who should receive study-related
correspondence from the CIRB. All Research Staff will receive access to the Participant’s Area of the CIRB website
(www.ncicirb.org). Access to the Participant’s Area is necessary for IRB and Research Staff to view and download studyrelated documents to use during facilitated review or to save in the regulatory file. User names and passwords for the
Participant’s Area of the Website will be sent via email.
1. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 16 of 45

NCI CIRB Institution Enrollment Worksheet
Section A: Research Staff Information
6. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

7. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

8. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

9. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

10. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 17 of 45

NCI CIRB Institution Enrollment Worksheet
Section A: Research Staff Information
11. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

12. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

13. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

14. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

15. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

All Research Staff from your Institution involved in Cooperative Group trials should be listed. If you need to add more
Research Staff, please email the CIRB Help Desk at ncicirbcontact@emmes.com for the appropriate form.

Version 12/10/2010

Page 18 of 45

Section A: Information About Institutions Identified On Your Federal Wide Assurance (FWA) As
‘Institutional Components’
Please list all Institutional Components, if any, over which the Institution has legal authority that operate under a different
name and participate in Cooperative Group trials approved by the CIRB. This information is also listed on your
Institution’s FWA in the ‘Institutional Components’ section. If you need to add more Institutions, please email the CIRB
Help Desk at ncicirbcontact@emmes.com for the appropriate form.

Institution #1
Institution Name
NCI Institution Code
Street Address
Street Address #2
City

State

Zip

State

Zip

State

Zip

State

Zip

State

Zip

State

Zip

Institution #2
Institution Name
NCI Institution Code
Street Address
Street Address #2
City
Institution #3
Institution Name
NCI Institution Code
Street Address
Street Address #2
City
Institution #4
Institution Name
NCI Institution Code
Street Address
Street Address #2
City
Institution #5
Institution Name
NCI Institution Code
Street Address
Street Address #2
City
Institution #6
Institution Name
NCI Institution Code
Street Address
Street Address #2
City

Version 12/10/2010

Page 19 of 45

Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your
Institution On Their Federal Wide Assurance (FWA)
Are there IRB(s) at other institutions that have designated on their FWA (item #5) an IRB listed in Section A of
this worksheet? Yes/No
If No, go to Section C on page 35.
If Yes, note that the IRBs listed below will not have the authority to perform a facilitated review since they are
depending on your IRB’s review. Please provide information for each IRB relying on an IRB from your Institution
for review of Cooperative Group studies approved by the CIRB. Contact information for Investigators and
Research Staff affiliated with each IRB is required. There is space for each IRB to supply contact information for
up to three Investigators and up to five Research Staff. If you need more space for additional Investigators or
Research Staff, email the CIRB Helpdesk at ncicirbcontact@emmes.com for the appropriate form.
All Investigators and Research Staff will receive access to the Participant’s Area of the CIRB website (www.ncicirb.org).
Access to the Participant’s Area is necessary for IRB and Research Staff to view and download study-related documents
to use during facilitated review or to save in the regulatory file. User names and passwords for the Participant’s Area of
the Website will be sent via email.

IRB # 1 Information
IRB Name
IRB Registration Number
Is this IRB the IRB of Record for an entire Community Clinical
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
institution (Yes/No)?
Is this IRB the IRB of Record for an entire for a Minority-Based
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
IRB Institution Information
Institution Name
NCI Institution Code

Name of CCOP
Name of CCOP
Name of MBCCOP
Name of MBCCOP
Name of Cancer Center
Name of College, University, or Medical School

FWA Number

Street Address
Street Address #2
City
State
Is this Institution a participating member of a CCOP? Yes/No

Zip
Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person Name
Email Address
Telephone Number (

)

DRAFT Version 10/29/2010

First
-

Last
Extension

Page 20 of 45

NCI CIRB Institution Enrollment Worksheet
Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your Institution on Their Federal
Wide Assurance (FWA)
1. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

1. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
2. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
3. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

3. Investigator Institution Information

Institution Name

NCI Institution Code

Zip
FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

Version 12/10/2010

Page 21 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

All Investigators and Research Staff from Institutions with IRBs using your IRB should be listed. If you need to add more
Investigators or Research Staff, please email the CIRB Help Desk at ncicirbcontact@emmes.com for the appropriate
form.

Version 12/10/2010

Page 22 of 45

NCI CIRB Institution Enrollment Worksheet
Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your Institution on Their Federal
Wide Assurance (FWA)

IRB # 2 Information
IRB Name
IRB Registration Number
Is this IRB the IRB of Record for an entire Community Clinical
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
institution (Yes/No)?
Is this IRB the IRB of Record for an entire for a Minority-Based
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
IRB Institution Information
Institution Name
NCI Institution Code

Name of CCOP
Name of CCOP
Name of MBCCOP
Name of MBCCOP
Name of Cancer Center
Name of College, University, or Medical School

FWA Number

Street Address
Street Address #2
City
State
Is this Institution a participating member of a CCOP? Yes/No

Zip
Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person Name
Email Address
Telephone Number (
)

Version 12/10/2010

First
-

Last
Extension

Page 23 of 45

)

Extension

Street Address
Street Address #2
City

State

Zip

1. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
2. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

)

Extension

Street Address
Street Address #2
City

State

3. Investigator Institution Information

Institution Name

NCI Institution Code

Zip
FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

Version 12/10/2010

Page 24 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

Page 25 of 45

NCI CIRB Institution Enrollment Worksheet
Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your Institution on Their Federal
Wide Assurance (FWA)

IRB # 3 Information
IRB Name
IRB Registration Number
Is this IRB the IRB of Record for an entire Community Clinical
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
institution (Yes/No)?
Is this IRB the IRB of Record for an entire for a Minority-Based
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
IRB Institution Information
Institution Name
NCI Institution Code

Name of CCOP
Name of CCOP
Name of MBCCOP
Name of MBCCOP
Name of Cancer Center
Name of College, University, or Medical School

FWA Number

Street Address
Street Address #2
City
State
Is this Institution a participating member of a CCOP? Yes/No

Zip
Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person Name
Email Address
Telephone Number (
)

Version 12/10/2010

First
-

Last
Extension

Page 26 of 45

)

Extension

Street Address
Street Address #2
City

State

Zip

1. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
2. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

)

Extension

Street Address
Street Address #2
City

State

3. Investigator Institution Information

Institution Name

NCI Institution Code

Zip
FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

Version 12/10/2010

Page 27 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

Page 28 of 45

NCI CIRB Institution Enrollment Worksheet
Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your Institution on Their Federal
Wide Assurance (FWA)

IRB # 4 Information
IRB Name
IRB Registration Number
Is this IRB the IRB of Record for an entire Community Clinical
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
institution?
Is this IRB the IRB of Record for an entire for a Minority-Based
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
IRB Institution Information
Institution Name
NCI Institution Code

Name of CCOP
Name of CCOP
Name of MBCCOP
Name of MBCCOP
Name of Cancer Center
Name of College, University, or Medical School

FWA Number

Street Address
Street Address #2
City
State
Is this Institution a participating member of a CCOP? Yes/No

Zip
Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person Name
Email Address
Telephone Number (
)

Version 12/10/2010

First
-

Last
Extension

Page 29 of 45

)

Extension

Street Address
Street Address #2
City

State

Zip

1. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Investigator # 2 Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
2. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

3. Investigator Institution Information

Institution Name

NCI Institution Code

Zip
FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

Version 12/10/2010

Page 30 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

Page 31 of 45

NCI CIRB Institution Enrollment Worksheet
Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your Institution on Their Federal
Wide Assurance (FWA)

IRB # 5 Information
IRB Name
IRB Registration Number
Is this IRB the IRB of Record for an entire Community Clinical
Oncology Program (CCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating CCOP
institution? (Yes/No)
Is this IRB the IRB of Record for an entire for a Minority-Based
Community Clinical Oncology Program (MBCCOP)? (Yes/No)
Does this IRB serve as the IRB of Record for a participating MBCCOP
institution? (Yes/No)
Does this IRB serve as the IRB of record for an NCI-designated
Cancer Center? (Yes/No)
Does this IRB review adult Cooperative Group phase 3 and/or
pediatric phase 2, 3 or pilot studies for a college, university, or medical
school? (Yes/No)
IRB Institution Information
Institution Name
NCI Institution Code

Name of CCOP
Name of CCOP
Name of MBCCOP
Name of MBCCOP
Name of Cancer Center
Name of College, University, or Medical School

FWA Number

Street Address
Street Address #2
City
State
Is this Institution a participating member of a CCOP? Yes/No

Zip
Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
IRB Contact Information
IRB Contact Person Name
Email Address
Telephone Number (
)

Version 12/10/2010

First
-

Last
Extension

Page 32 of 45

NCI CIRB Institution Enrollment Worksheet
Section B: Information About IRBs at Other Institutions Who Have Designated an IRB at Your Institution on Their Federal
Wide Assurance (FWA)
1. Investigator Information
Investigat or Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

1. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
2. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Institution Information

Institution Name

NCI Institution Code

FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

)

Extension

Street Address
Street Address #2
City

State

3. Investigator Institution Information

Institution Name

NCI Institution Code

Zip
FWA Number

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No

Version 12/10/2010

Page 33 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

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NCI CIRB Institution Enrollment Worksheet
Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your Institution On Their
FederalWide Assurance (FWA)

Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your
Institution On Their FederalWide Assurance (FWA)
Are there Institutions that do not have an IRB and have designated an IRB listed in Section B on their OHRP
FWA? Yes / No
If no, please return the completed worksheet to the CIRB Operations Office via email to
ncicirbcontact@emmes.com.
If yes, please provide information for each Institution without an IRB that is relying on an IRB from your
Institution for review of Cooperative Group studies approved by the CIRB. Contact information for Investigators
and Research Staff affiliated with each Institution is required. There is space for five Institutions and for each
Institution to supply contact information for up to three Investigators and up to five Research Staff. If you need
more space for additional Institutions, Investigators or Research Staff, email the CIRB Helpdesk at
ncicirbcontact@emmes.com for the appropriate form
All Investigators and Research Staff will receive access to the Participant’s Area of the CIRB website (www.ncicirb.org).
Access to the Participant’s Area is necessary for IRB and Research Staff to view and download study-related documents
to use during facilitated review or to save in the regulatory file. User names and passwords for the Participant’s Area of
the Website will be sent via email.

Institution # 1 Information
Institution Name
FWA Number

NCI Institution Code

Street Address
Street Address #2
City

State

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Contact Person Information
First

Contact Person Name

Last

Email Address
Telephone Number (

Version 12/10/2010

)

Extension

Page 35 of 45

NCI CIRB Institution Enrollment Worksheet
Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your Institution On Their
FederalWide Assurance (FWA)
1. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

3. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 36 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

All Investigators and Research Staff from Institutions without IRBs using your IRB should be listed. If you need to add more
Investigators or Research Staff, please email the CIRB Help Desk at ncicirbcontact@emmes.com for the appropriate
form.
If there are no other Institutions relying on an IRB at your institution, you have completed this form. Please review and return
the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

Version 12/10/2010

Page 37 of 45

NCI CIRB Institution Enrollment Worksheet
Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your Institution On Their
FederalWide Assurance (FWA)

Institution # 2 Information
Institution Name
FWA Number

NCI Institution Code

Street Address
Street Address #2
City

State

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Contact Person Information
First

Contact Person Name

Last

Email Address
Telephone Number (

)

Extension

1. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

2. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

3. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 38 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

Page 39 of 45

NCI CIRB Institution Enrollment Worksheet
Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your Institution On Their
FederalWide Assurance (FWA)

Institution # 3 Information
Institution Name
FWA Number

NCI Institution Code

Street Address
Street Address #2
City

State

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Contact Person Information
First

Contact Person Name

Last

Email Address
Telephone Number (

)

Extension

1. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

)

Extension

Street Address
Street Address #2
City

State

Zip

3. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 40 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Rese arch Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

Page 41 of 45

NCI CIRB Institution Enrollment Worksheet
Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your Institution On Their
FederalWide Assurance (FWA)

Institution # 4 Information
Institution Name
FWA Number

NCI Institution Code

Street Address
Street Address #2
City

State

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Contact Person Information
First

Contact Person Name

Last

Email Address
Telephone Number (

)

Extension

1. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

)

Extension

Street Address
Street Address #2
City

State

Zip

3. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 42 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Version 12/10/2010

Page 43 of 45

NCI CIRB Institution Enrollment Worksheet
Section C: Information About Institutions Without IRBs Who Have Designated an IRB at Your Institution On Their
FederalWide Assurance (FWA)

Institution # 5 Information
Institution Name
FWA Number

NCI Institution Code

Street Address
Street Address #2
City

State

Zip

Is this Institution a participating member of a CCOP? Yes/No

Name of CCOP

Is this Institution a participating member of a MBCCOP? Yes/No

Name of MBCCOP

Is this Institution an NCI-designated Cancer Center? Yes/No
Contact Person Information
First

Contact Person Name

Last

Email Address
Telephone Number (

)

Extension

1. Investigator Information
Investigator Name
First
Last
Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

State

Zip

)

Extension

Street Address
Street Address #2
City

State

Zip

3. Investigator Information
Investigator Name

First

Last

Cooperative Group Affiliations (please select all Cooperative Groups with which this Investigator is affiliated)
(ACOSOG , CALGB , COG , ECOG , GOG , NCCTG , NCIC CTG , NSABP , RTOG , SWOG
NCI Investigator Number
Email Address
Telephone Number (

)

Extension

Street Address
Street Address #2
City

Version 12/10/2010

State

Zip

Page 44 of 45

)

First

Title/Role

Email Address

Telephone Number (

)

Last
Extension

Institution Name
Street Address
Street Address #2
City

State

2. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

3. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

4. Research Staff Name

First

Title/Role
Telephone Number (

Zip
Last

Email Address
)

Extension

Institution Name
Street Address
Street Address #2
City

State

5. Research Staff Name

First

Title/Role

Email Address

Telephone Number (

)

Zip
Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

All Investigators and Research Staff from Institutions without IRBs using your IRB should be listed. If you need to add more
Investigators or Research Staff, please email the CIRB Help Desk at ncicirbcontact@emmes.com for the appropriate
form
If there are no other Institutions relying on an IRB at your institution, you have completed this form. Please review and return
the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

Version 12/10/2010

Page 45 of 45

File Type	application/pdf
File Title	Attachment 2A - NCI CIRB Enrollment Form_110110.doc
Author	jdugan
File Modified	0000-00-00
File Created	2010-10-29