Form 5 Research Staff 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.

Research Staff at Signatory Institution
(All contact forms must be submitted by the local IRB of the signatory institution.)
Please provide the CIRB with contact information for Research Staff from your signatory institution who should
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
Research Staff
First
Name
Title/Role
Email Address
Telephone Number (

)

-

Last

Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Remove Research Staff
NOTE: The individuals listed below will no longer receive study-related correspondence from the CIRB and will
have their usernames and passwords revoked.
First Name

Last Name

Role

Institution Name