Form 9 Component Institution 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.

Component Institution at Signatory Institution
(All contact forms must be submitted by the local IRB of the signatory institution.)
Please provide information for each new component institution for which the signatory institution has legal
authority to 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.
Add
Revise
Component Information
at Signatory Institution:
NCI Institution Code
Street Address
Street Address #2
City
Remove Component(s)
Institutional Component Name

Institution Name

State

Zip