IRB Authorization Agreement Request Form
Instructions: An IRB Authorization Agreement (IAA) is a mechanism whereby one institution relies on another for IRB review and approval. Submit this form to request an IRB Authorization Agreement in which a Harvard IRB can serve as either the Reviewing or Relying Institution. As the Reviewing Institution, an Institution is responsible for IRB review and continuing oversight. As the Relying Institution, an Institution cedes IRB review and continuing oversight to the Reviewing Institution.
- If other Harvard Catalyst Institutions are involved do not use this form, but visit to submit a Cede Review Form.
- If this request is not being submitted through Catalyst and you are requesting that a Harvard IRB be the Relying institution, please submit this form directly to the appropriate Harvard IRB office and not through the IRB Submission System.
A. PROTOCOL INFORMATION
Protocol Number:
Protocol Title:
Principal Investigator / Degree(s): / /
Summary of research activities (purpose, hypotheses, and procedures). For institutions relying on a Harvard IRB, include the specific role/responsibilities of investigators that will be covered under this agreement
(i.e. how relying institution is engaged):
B. DESIGNATING the REVIEWING and RELYING INSTITUTION
1. Reviewing Institution Information
Check here if this request is to designate a Harvard IRB as the Reviewing Institution, and skip to question #3:
a. Name of Institution:
b. Federalwide Assurance (FWA)* number:
c. IRB Registration* number:
d. IRB Contact Name/Email/Phone Number:
e. Signatory Official Name:
f. Signatory Official Contact Address/Phone Number:
*Federalwide Assurance and IRB Registration numbers can be found at
2. Reviewing Institution’s Protocol Information
a. Protocol Number: ; Not available
b. Principal Investigator:
c. Required Documentation attached:
Copy of the IRB Application
Copy of the Grant
Copy of the IRB Approval
3. Relying Institution Information
Check here if this request is to designate a Harvard IRB as the Relying Institution, and skip to question #4:
a. Name of Institution:
b. Principal Investigator(s):
Federalwide Assurance (FWA)* number:
c. IRB Registration* number:
d. IRB Contact Name/Email/Phone Number:
e. Signatory Official:
f. Signatory Official Contact Address/Phone Number:
*Federalwide Assurance and IRB Registration numbers can be found at
4. Hasa HarvardIRB previously approved this protocol? Yes No
If yes, provide the IRB of Record protocol number:
If no and this request is to designate a Harvard IRB as the Reviewing Institution, submit an Initial Application.
5. Will any human research activities, including subject recruitment, enrollment, and/or study interventions/interactions, occur at a Harvard site? Yes No
If yes, please describe the activities* and the location in detail here:
*The Harvard IRBreceiving this application may decline a request to rely on another institution and retain jurisdiction over certain research activities. For more information, please visit the website for the IRB receiving this request:
C. HARVARD ENTERPRISE SECURITY POLICY
Check here to confirm that you have read Harvard Enterprise Security Policy, available at and certify that you will comply with the terms of this policy:
D. PRINCIPAL INVESTIGATOR SIGNATURE
______
Principal Investigator’s SignatureDate
IRB Authorization Request | HRP-224 | Version date: March 26, 2014 | Page 1 of 2
University Area IRB
Longwood Medical Area IRB