Form 57 Annual PI Worksheet

€i9

......

Pagelof4

...
...,c-�
_

Add Note

l • Annual Pl Worksheet Ab()ul Local Context 04 Pl lnformatic:m

Expiration Date: 05/31/2024

0MB #: 0925-0753

STATEMENT OF CONFIDENTIALITY
The purpose of the information collection is to conduct reviews of clinical trial studies. NCI guidelines mandate the participation of
institutions in the CIRO for Network group studies. You are being requested to complete this instrument so that we can conduct
activities involved with the operations of the NCI CIRB Initiative. Although your participation in Network group 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 collect ion of information is estimated to average 20 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid 0MB 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 (0925-0753). Do not return the completed form to this address.

Reason for submission:

Add Note

View Audit

Add Note

View Audit

(Required}

0 First Submission of the Annual Principal Investigator worksheet About Local Context
0 Revised Submission of the Annual Principal Investigator Worksheet About Local Context
Signatory Institution Information
Submitting User Information

Campbell, Brian
Email:

bcampbell@emmes.com

1. Enter Principal Investigator email address.

Add Note

(Required)
If the PJ's name does not appear above the email address field, this means there is
no active account associated with this email address. Please confirm the email
address is correct and that it is the email address associated with the PI in JAM.
If the email address is correct and the PI name still does not appear, you will need
to complete a Signatory Personnel Form to add the PI to the CIRB roster and send
it to your Signatory Institution Pn·mary Contact Person for approval and
submission to the NCI CIRB Helpdesk for inclusion onto to your institution's roster
with NCI ClRB.

Add Note

2. Name of Signatory Institution

Children's Oncology GroupJ•]
calculated Field

No answer provided.campbeU, Anne M M.D. *FIRST SUBMISSION

[Research Staff
3. How many sub-investigators do you have supporting you in conducting CIRB-approved research?

Add Note

View Audit

Add Note

1

(R.equi,-ed)

4. How many research nurses/CRAs do you have supporting you in conducting CI RB-approved research?

Add Note