DATE
PI NAME:
STUDY TITLE:
IRB NUMBER:
The attached translated document titled, “<<Title of Translated Document>>” is an accurate
<<name of language>> interpretation of the English version dated <<date of English version of
document>>.
I am a <INSERT SOMETHING SUCH AS CERTIFIED TRANSLATOR, NATIVE SPEAKER, etc. BASED ON
QUALIFICATIONS> and assure the University of Utah Institutional Review Board that that this
translation is accurate to the best of my knowledge.
I also assure the University of Utah IRB that I am acting independently from the principal
investigator, and am not affiliated with this study in any way.
If you have any questions, please contact me using the information below.
Phone:
Fax:
Email:
Thank you,
________________________________
Signature of Translator/Reviewer
________________________________
Printed Name of Translator/Reviewer