Form 2c NCI CIRB Signatory

NCI CIRB SIGNATORY INSTITUTION ENROLLMENT FORM

The NCI CIRB Signatory Institution Enrollment Form is a Microsoft Word document that must be completed electronically. Once the Form is completed, save it as a Word document, then email it to the CIRB Operations Office at ncicirbcontact@emmes.com.

• Section A: Signatory Institution Information 2

• Section B: Component Institutions as Defined by the CIRB 3

• Section C: Signatory Institution Principal Investigator Information 4

• Section D: Sub-Investigator Information 7

• Section E: Research Staff Information 10

• Section F: Affiliate Institutions as Defined by the CIRB 13

OMB#: 0925 – 0625

Expiry Date: 01/31/2014

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of your participation in the NCI CIRB is protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the NCI CIRB at any time. Refusal to participate will not affect your benefits in any way. The information collected will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the NCI CIRB. Information provided will be combined for all participants and reported as summaries. You are being requested to complete this instrument so that we can conduct activities involved with the operations of NCI CIRB Initiative.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 4 hours 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 (0925-0625). Do not return the completed form to this address.

Section A: Signatory Institution Information (Institution of Signatory Official who signs the Authorization Agreement)
Signatory Institution Name      
Street Address      
Street Address #2      
City      		State   			Zip      
OHRP Federalwide Assurance (FWA) Number      
NCI Institution Code      			Using which CIRB: Adult-Late Phase Emphasis Pediatric Adult-Early Phase Emphasis
Is this Institution a participating member of a Community Clinical Oncology Program (CCOP)? (Yes, No)			Name of CCOP      
Is this Institution a participating member of a Minority-Based Community Clinical Oncology Program (MBCCOP)? (Yes, No)			Name of MBCCOP      
Is this Institution an NCI-designated Cancer Center? (Yes, No)			Name of NCI-designated Cancer Center      
Identify the Signatory Official at the Signatory Institution
First Name      	Last Name      					Degree (optional)      
Title/Role      	Email Address      
Telephone Number (   )   -    	Extension      
Identify the person(s) who will serve as the Signatory Institution Primary Contact
Signatory Institution Primary Contact Information
First Name      	Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    	Extension      
Signatory Institution Primary Contact Information
First Name      	Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    	Extension      
Signatory Institution Primary Contact Information
First Name      	Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    	Extension      

Institution GUID (Internal Use Only)

     

Section B: Component Institutions as Defined by the CIRB

Component Institutions are defined by the CIRB as meeting ALL of the following criteria:

• the Component Institution operates under a different name than the Signatory Institution, but the Signatory Institution has legal authority for the Component Institution;

• the FWA number for the Component Institution is the same as the Signatory Institution;

• the local context considerations of the Component Institution are the same as the Signatory Institution. Local context considerations are reported by the Signatory Institution in the Annual Institution Worksheet About Local Context;

• the boilerplate language and institutional requirements of the Component Institution are the same as the Signatory Institution. The boilerplate language and institutional requirements are reported by the Signatory Institution in the Annual Institution Worksheet About Local Context; and

• the conduct of research at the Component Institution is monitored by the same office as the Signatory Institution.

List all Component Institutions that meet the CIRB’s definition.

NOTE: Information about Affiliate Institutions, and related Investigators and Research Staff information, is captured in Section F.

Component Institution Information
Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      
Component Institution Information
Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      
Component Institution Information
Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      
Component Institution Information
Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      
Component Institution Information
Institution Name      
NCI Institution Code      
Street Address      
Street Address #2      
City      	State   	Zip      

Section C: Signatory Institution Principal Investigator Information Signatory Institution Principal Investigators (PIs) are individuals designated to open studies using the NCI CIRB. Provide contact information for PIs from the Signatory and/or Component Institutions. Signatory Institution Principal Investigators will receive information about how to open a study in a separate email.
Signatory Institution Principal Investigator Information
First Name      		Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      

Click here to add more Signatory Institution Principal Investigators.

Click here to move to the next section.

Signatory Institution Principal Investigator Information
First Name      		Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      

Click here to add more Signatory Institution Principal Investigators.

Click here to move to the next section.

Signatory Institution Principal Investigator Information
First Name      		Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      
Signatory Institution Principal Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      			Email Address      
Telephone Number (   )   -    			Extension      

If you need to add more Signatory Institution Principal Investigators from the Signatory and/or Component Institutions, access the form located at the following URL https://www.ncicirb.org/Personnel_SignatoryInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Section D: Sub-Investigator Information Sub-investigators are those who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Provide the contact information for Sub-Investigators from the Signatory and/or Component Institutions. Sub-investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      

Click here to add more Sub-Investigators.

Click here to move to the next section.

Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      

Click here to add more Sub-Investigators.

Click here to move to the next section.

Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      
Sub-Investigator Information
First Name      	Last Name      	Degree      
NCI Investigator Number      	Email Address      
Telephone Number (   )   -    	Extension      

If you need to add more Sub-Investigators from the Signatory and/or Component Institutions, access the form located at the following URL https://www.ncicirb.org/Personnel_SignatoryInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Section E: Research Staff Information Provide contact information for Research Staff from the Signatory and/or Component Institutions who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Click here to add more Research Staff.

Click here to move to the next section.

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

Click here to add more Research Staff.

Click here to move to the next section.

Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      

If you need to add more Research Staff from the Signatory and/or Component Institutions, access the form located at the following URL https://www.ncicirb.org/Personnel_SignatoryInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Section F: Affiliate Institutions as Defined by the CIRB

Affiliate Institutions are defined by the CIRB as meeting ALL of the following criteria:

• the local context considerations of the Affiliate Institution are the same as the Signatory Institution. Local context considerations are reported by the Signatory Institution in the Annual Institution Worksheet About Local Context;

• the boilerplate language and institutional requirements of the Affiliate Institution are the same as the Signatory Institution. The boilerplate language and institutional requirements are reported by the Signatory Institution in the Annual Institution Worksheet About Local Context; and

• the conduct of research at the Affiliate Institution is monitored by the same office as the Signatory Institution.

List each Affiliate Institution that meets the CIRB’s definition, and provide contact information for Sub-Investigators and Research Staff for each Affiliate Institution.

Affiliate Institution Information
Institution Name      
FWA Number      						NCI Institution Code      
Is this Institution an NCI-designated Cancer Center? (Yes, No)
Sub-Investigator Information Sub-investigators are those who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Provide the contact information for Sub-Investigators from the Affiliate Institution listed above. Sub-investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      				Last Name      				Degree      
NCI Investigator Number      					Email Address      
Telephone Number (   )   -    					Extension      
Sub-Investigator Information
First Name      				Last Name      				Degree      
NCI Investigator Number      					Email Address      
Telephone Number (   )   -    					Extension      
Sub-Investigator Information
First Name      				Last Name      				Degree      
NCI Investigator Number      					Email Address      
Telephone Number (   )   -    					Extension      
Sub-Investigator Information
First Name      				Last Name      				Degree      
NCI Investigator Number      					Email Address      
Telephone Number (   )   -    					Extension      
Sub-Investigator Information
First Name      				Last Name      				Degree      
NCI Investigator Number      					Email Address      
Telephone Number (   )   -    					Extension      
Sub-Investigator Information
First Name      				Last Name      				Degree      
NCI Investigator Number      					Email Address      
Telephone Number (   )   -    					Extension      
If you need to add more Sub-Investigators from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.
Research Staff Information Provide contact information for Research Staff from the Affiliate Institution listed above who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      					Degree (optional)      
NCI Person ID Number      	Title/Role      						Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Research Staff from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.
If there are no other Affiliate Institutions, you have completed this form. Please review and return the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

Additional Affiliate Institution Information List each Affiliate Institution that meets the CIRB’s definition, and provide contact information for Sub-Investigators and Research Staff for each Affiliate Institution.
Institution Name      
FWA Number      			NCI Institution Code      
Is this Institution an NCI-designated Cancer Center? (Yes, No)
Sub-Investigator Information Sub-investigators are those who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Provide the contact information for Sub-Investigators from the Affiliate Institution listed above. Sub-investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Sub-Investigators from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Research Staff Information Provide contact information for Research Staff from the Affiliate Institution listed above who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Research Staff from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.
If there are no other Affiliate Institutions, you have completed this form. Please review and return the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

Additional Affiliate Institution Information List each Affiliate Institution that meets the CIRB’s definition, and provide contact information for Sub-Investigators and Research Staff for each Affiliate Institution.
Institution Name      
FWA Number      			NCI Institution Code      
Is this Institution an NCI-designated Cancer Center? (Yes, No)
Sub-Investigator Information Sub-investigators are those who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Provide the contact information for Sub-Investigators from the Affiliate Institution listed above. Sub-investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Sub-Investigators from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Research Staff Information Provide contact information for Research Staff from the Affiliate Institution listed above who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Research Staff from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.
If there are no other Affiliate Institutions, you have completed this form. Please review and return the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

Additional Affiliate Institution Information List each Affiliate Institution that meets the CIRB’s definition, and provide contact information for Sub-Investigators and Research Staff for each Affiliate Institution.
Institution Name      
FWA Number      			NCI Institution Code      
Is this Institution an NCI-designated Cancer Center? (Yes, No)
Sub-Investigator Information Sub-investigators are those who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Provide the contact information for Sub-Investigators from the Affiliate Institution listed above. Sub-investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Sub-Investigators from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Research Staff Information Provide contact information for Research Staff from the Affiliate Institution listed above who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Research Staff from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.
If there are no other Affiliate Institutions, you have completed this form. Please review and return the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

Additional Affiliate Institution Information List each Affiliate Institution that meets the CIRB’s definition, and provide contact information for Sub-Investigators and Research Staff for each Affiliate Institution.
Institution Name      
FWA Number      			NCI Institution Code      
Is this Institution an NCI-designated Cancer Center? (Yes, No)
Sub-Investigator Information Sub-investigators are those who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Provide the contact information for Sub-Investigators from the Affiliate Institution listed above. Sub-investigators will receive information about how to access the CIRB website in a separate email.
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
Sub-Investigator Information
First Name      	Last Name      			Degree      
NCI Investigator Number      		Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Sub-Investigators from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.

Research Staff Information Provide contact information for Research Staff from the Affiliate Institution listed above who have a significant role in research, under the direction of the Signatory Institution Principal Investigator, and need access to the CIRB website. Research Staff will receive information about how to access the CIRB Website in a separate email.
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
Research Staff Information
First Name      			Last Name      		Degree (optional)      
NCI Person ID Number      	Title/Role      			Email Address      
Telephone Number (   )   -    		Extension      
If you need to add more Research Staff from this Affiliate Institution, access the form located at the following URL https://www.ncicirb.org/Personnel_AffiliateInstitution.doc. Complete the form, save it as a Word document, and email it with your completed Enrollment Form to the CIRB Operations Office at ncicirbcontact@emmes.com.
If there are no other Affiliate Institutions, you have completed this form. Please review and return the completed worksheet to the CIRB Operations Office via email to ncicirbcontact@emmes.com. Thank you.

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