University of Pittsburgh Human Research Protection Office (HRPO)

Application for an External Institution to Serve as IRB of Record

Instructions for Use: To be completed when a Pitt/UPMC investigator is submitting an initial request to rely on an IRB outside of UPitt for a multi-centered research study.

Please email and include the following:

·  This completed form

·  A protocol summary or the human subjects section of the grant application

·  A copy of the Central IRB agreement the external site would request us to sign (if available)

Study Title:
Pitt/UPMC Principal Investigator:
Name and Degree:
Department:
Email Address:
Contact Person for Pitt/UPMC research team:
Name:
Department:
Email Address:
Is use of a Central IRB a requirement of funding? Yes No
List Funding Source(s)
Federal Government-specify:
Other-specify:
Primary Awardee
Pitt/UPMC
Institution being requested to act as IRB of record
Other-specify:
Name of the Institution you are requesting to act as IRB of record:
Federal Wide Assurance (FWA) # of IRB you are requesting to rely on:
Does this institution have AAHRPP accreditation? Yes No
Provide the following information for the lead investigator at the institution that will act as IRB of record:
Name and Degree:
Email Address:
Provide the following information for the IRB representative at the institution you are requesting to act as IRB of record
Name:
Email address:
Telephone number:
______
Signature of the Pitt/UPMC Principal Investigator Date

**********************************************************************************

Pitt HRPO Use Only
Pitt HRPO Determination
Pitt IRB will cede IRB review to external institution / Yes
No
Pitt HRPO Risk Assessment / Minimal risk
Greater than minimal risk
Minimal Risk Research: Pitt HRPO Determination
Name of Pitt HRPO Providing Authorization:
______
Signature of Person Providing Authorization Date
Greater than Minimal Risk Research: Pitt Institutional Official Authorization
Vice Provost for Research Conduct and Compliance:
Name of Designee:
______
Signature of Person Providing Authorization Date

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