Request to Act as Single IRB Form

* = Required Fields

Name of the Requesting UMMC PI*
UMMC PI Email Address*
UMMC Department(s) engaged in this research*
Protocol Title*
Funding Source/Agency*
How many sites are engaged in human subjects research based on funding and/or the protocol (including UMMC)?*
Please list all relying sites.*
Why is this reliance agreement being requested?*	Select one... Sponsor requirement Consortium arrangement Preference of the collaborators Other
If Other, please list here.
Are all relying sites SMART IRB Signatories?*	Select one... Yes No
Scope of UMMC's research engagement* Prime Awardee Protocol Development Recruiting Participants Obtaining Consent/Permission/Assent from Participants Performing a research intervention or activities directly involving human subjects, identifiable information, and/or identifiable biospecimens Data Analysis (either aggregate or deidentified data) Other
If Other, please list here.
Are all relying sites located in the United States?*	Select one... Yes No
Are all relying sites AAHRPP accredited?*	Yes No
Provide a Lay Summary of the research to be conducted at the relying sites.*
Provide PI names and IRB Contact information for all relying sites, if known.*
Do any of the potential relying sites have recent warning letters or open investigations with either OHRP or the FDA?*	Yes No