Form 1 CIRB Final Video Submission

CIRB PARTICIPANT RECRUITMENT MATERIAL

VIDEO SUBMISSION FORM

OMB #0925-0753 Expiration Date: 3/31/2026

The purpose of the information collection is to conduct reviews of clinical trial studies.  NCI guidelines mandate the participation of institutions in the CIRB 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 collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0753). Do not return the completed form to this address.

If you have any questions regarding the completion of this application, contact the CIRB Helpdesk at support@ncicirbcontact.zendesk.com or 888-657-3711.

This application has been designed to meet the regulatory requirements for review, so answer each question as completely as possible.

• All answers must be in lay language.

• If an answer to any question cannot be provided, provide an explanation for the missing answer.

• If you have any questions regarding the completion of this application, contact the CIRB Helpdesk at ncicirbcontact@emmes.com or 888-657-3711.

Study ID      

Study Title      

Protocol Version Date      

Event      

Study Chair      

What is the eligible population for this study?

Adult only

Pediatric only

Adult and Adolescents and Young Adults (AYA)

Pediatric and Adolescents and Young Adults (AYA)

Adult and Pediatric

Adult, Pediatric, and Adolescents and Young Adults (AYA)

2.0 Participant-Directed or Recruitment Video Material

2.1 Link to online video or file:      

2.2 Provide a brief description of the video being submitted:      

2.4 Draft scripts or story boards are required to be reviewed by the CIRB prior to finalization. Provide the date of CIRB approval of the draft material:      

2.5 Attach the file for the final recruitment video, if applicable:

Submit the completed form via email to adultcirb@emmes.com, earlyphasecirb@emmes.com, pediatriccirb@emmes.com, or cpccirb@emmes.com.

Version Date 01AUG2023 Page 1 of 2