Single IRB Review

Main Content

Request to Act as Single IRB Form

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? *

If Other, please list here.

Are all relying sites SMART IRB Signatories? *

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? *

Are all relying sites AAHRPP accredited? *

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? *