Form 12 Request for 30-Day Access Form

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

OMB#: 0925 – xxxx Expiry Date: xx/xx/xxxx
STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized under 42 USC 285a. Your participation is completely voluntary. You are
subject to no penalty if you choose not to provide all or any part of the requested information. 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.

Request for 30-Day NCI CIRB Website Access
The NCI CIRB Operations Office will provide 30-day access to the Participant’s Area of the
CIRB website for those IRBs that are interested in joining the Initiative. Local IRBs have
requested short-term access to the restricted side of the CIRB website so they may access review
documents prior to enrolling in the CIRB Initiative. By completing and signing this request, you
acknowledge that you are being given access to confidential information. These documents are
for your information regarding participation in the NCI CIRB Initiative and should not be used
for any other purpose.
Complete the information below and return the signed document to the CIRB Operations Office
via Fax to (301) 560-6538 OR scan and email to ncicirbcontact@emmes.com. Access via a user
name and password will be given to the person named in line #1. Access will automatically
expire 30 days from the day the Operations Office sends the user name and password.
1.

Name:

2.

Role:

_____________________________
IRB Contact
Research Staff
Other __________________

3.

Telephone:

_____________________________

4.

Email:

_____________________________

5.

Institution Name: _________________________________________

6.

Board Type:

Adult

7.

Investigator’s Name:

___________________________________

Pediatric

Both

Version date 3.18.08

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

8.

Investigator’s Cooperative Group Affiliation(s):
ACOSOG

CALGB

COG

ECOG

GOG

NCCTG

NCIC CTG

NSABP

RTOG

SWOG

______________________________

_______________________

Signature

Date

Version date 3.18.08