Form 16 CIRB New Board Member Contact Information Form

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 15 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.

Attachment 3C:
Board Member: CONTACT INFORMATION FORM
Member Information
Name :
Title:
Address:
Work Phone:
Cell Phone:
Fax:
Email:
¨ Please check here if this is the address you prefer to receive hard copies
of board materials
Personal Information (or to be used as alternate contact
information)
Address:
Home Phone:
Cell Phone 2:
Fax 2:
Email 2:
¨ Please check here if this is the address you prefer to receive hard copies
of board materials
New Board Member Orientation

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NCI CIRB Initiative

Alternate Contact (include if another person in your office should be
cc’ed on correspondence)
Name :
Title:
Address:
Phone:
Fax:
Email:

Please return this form to the Operations office via email
(jhorigan@emmes.com) or fax (301-560-6538).

New Board Member Orientation

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NCI CIRB Initiative