Form 3 RB Staff at Signatory Institution's IRB

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.

IRB Staff at Signatory Institution’s IRB
(All contact forms must be submitted by the local IRB of the signatory institution.)
Please provide contact information for new IRB Staff at an IRB from your signatory institution that reviews Cooperative
Group studies approved by the CIRB and 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
IRB Staff Information
Person Name
First
Title/Role
Telephone Number (
)
-

Last
Email Address
Extension

Institution Name
Street Address
Street Address #2
City

State

Zip

Remove IRB 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