weuest to ede Iw weie Vesion Apil Inspire health Serve with compas - PDF document

1 n n n n weƋuest to /ede Iw. weǀieǁ V
n n n n weƋuest to /ede Iw. weǀieǁ Veƌsion Apƌil ϴ, ϮϬϭϵ Inspire health. Serve with compassion. Be the difference. REQUEST TO CEDE IRB REVIEW TKLs form Ls needed wKen you want an outsLde InstLtutLonal RevLew Board to revLew your researcK. WorN wLtK your contact person at tKe proposed revLewLnJ IRB to complete atKLs completed form tKe IRB OffLce: 2. PrLsma +ealtK–Upstate prLncLpal LnvestLJator and credentLals3. Name and contact LnformatLon of person at PrLsma +ealtK–Upstate to contact about tKLs request 4. FundLnJ Sponsor 5. Requested RevLewLnJ IRB 6. Is tKe requested revLewLnJ IRB AA+RPP accredLted-? Yes . Is tKLs an FDA ReJulated Study ? Yes No weƋuest to /ede Iw. weǀieǁ Veƌsion Apƌil ϴ, ϮϬϭϵ . Reason for RelLance Request PrLmary PI’s Kome LnstLtutLon *rant-KoldLnJ LnstLtutLon IocatLon of researcK actLvLtLes +as already revLewed tKe study FundLnJ sponsor

2 ’s request Federal AJency Funded Sel
’s request Federal AJency Funded Select all tKat apply for tKe followLnJ sectLons.Types of research participants proposed from Prisma Health–Upstate None +ealtKy controls Adults CKLldren PreJnant women/fetuses Persons wLtK LmpaLred decLsLon-maNLnJ Students Employees OtKer vulnerable PopulatLon______________ Research activities proposed at Prisma Health–Upstate ObtaLnLnJ consent ResearcK InterventLons Date /Specimen use proposed at Prisma Health–Upstate None AnalysLs BanNLnJ CollectLon ReposLtory creatLon UtLlL]atLon of stored de-LdentLfLed tLssue Ancillary services proposed to be used at Prisma Health–Upstate EmerJency Department Iaboratory PatKoloJy NursLnJ PKarmacy RadLoloJy SurJery For IRB Office Use Only: Cede RevLew Do NOT Cede RevLew add comments below