Form 4 Investigator at Signatory Institution

National Cancer Institute
Central IRB Initiative

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 average 10 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.

Investigator at Signatory Institution
(All contact forms must be submitted by the local IRB of the signatory institution.)
Contact information for Investigators at each signatory institution is required. Please provide the CIRB with their
contact information so they may receive study-related correspondence from the CIRB. Usernames and passwords for
the Participant’s Area of the Website will be sent via email to those listed below.
Add
Revise
Investigator
First
Last
Name
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
Investigator Institution
Information
NCI Institution Code

State

Zip

Institution Name
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
Remove Investigator(s)
NOTE: The individuals listed below will no longer receive study-relat ed correspondence from the CIRB and will have their
usernames and passwords revoked.
First Name
Last Name
NCI Investigator
Institution Name
Number