Form 2C NCI IRB Enrollment Form REV

NIH NCI Central Institutional Review Board (CIRB) Initiative (NCI)

2C_NCI_CIRB_Enrollment_Form_REV

NCI CIRB Institution Enrollment Worksheet (Attach 2C)

OMB: 0925-0625

Document [doc]
Download: doc | pdf

Section A: Signatory Institution Information

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.




































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 National Cancer Institute (NCI) Central Institutional Review Board (CIRB) Initiative is protected by The Privacy Act of 1974, as amended. The purpose of the information collection is to conduct reviews of clinical trial studies. Although your participation in NCI-sponsored research and completion of the forms is voluntary, if you wish to participate in the CIRB, you must complete all questions on the form. The information you provide will be combined for all participants and reported as summaries. It will be kept private to the extent provided by law.

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.


File Typeapplication/msword
File TitleCIRB INSTITUTION QUESTIONNAIRE
AuthorAmparo Briggs
Last Modified ByJennifer Dugan
File Modified2013-11-13
File Created2013-06-25

© 2024 OMB.report | Privacy Policy