ROUTING FORM
IRB-HSR#:
OR
Submission #
The IRB-HSR cannot process this request without one of these numbers.
Submission Date:
Complete this form and attach it to the top of ALL submissions to the IRB-HSR Office.
Which IRB staff member did you work with on the pre-review of this submission?
IMPORTANT: If multiple documents are submitted, they must be submitted with a Document Submission Form.
You are encouraged to submit all large documents (e.g. sponsor’s protocols, investigators brochures) on a CD. They must be in
PDF format. The IRB # and Submission Date of the CD must be written directly on the CD.
A Document Submission Form must be submitted with the CD.
If another IRB is the IRB of record for this protocol, check an IRB below:
NCI CIRB (NCI Cooperative Group protocols)
NeuroNEXT CIRB (NeuroNEXT protocols)
Fred Hutchinson CIRB (CITN protocols)
Western IRB-(NCI Cooperative Group)
Other: Name
For IRB- HSR office use only
Receipt Date:
Type of Submission:
New Grant
New Protocol-Exempt/ Coded/ Not Engaged
New Protocol Expedited
New Protocol- Full Board
Follow up to Requests from Full Board Review of:
New Protocol
Modification
Modification - Attach Appropriate Modification Forms :
Personnel Change
Adverse Event Report
Advertisement
Protocol Violation/Enrollment Exception
Status Report
Study Closure
Other, Specify:
IND/IDE Annual Report
Revised Investigator Brochure
Check one item below
No changes required to protocol or consent
Changes required to protocol or consent (attach Modification Request Form and revised protocol and or consent)
CONTACT INFORMATION
Provide contact information for a representative who can answer any questions the IRB might have concerning this submission:
Approvals/receipt of acknowledgments will also be sent to the person listed below.
Contact Name:
Phone Number:
E-Mail Address:
Messenger Mail Box #:
____________________________________________________________________________
Select how you would like the IRB to send the approval/receipt of acknowledgment to you.
Return reply in messenger mail
I will pick up reply at Davis 5- Room 5293 Pick up Box
I will pick up reply from Morton Drive
Replies not picked up within 5 week days will be sent to the contact via Messenger Mail.
The IRB-HSR is unable to send approvals via regular mail unless the individual is not physically located at UVa.
Comments:
Website: http://www.virginia.edu/vpr/irb/hsr/index.html
Phone: 434-924-2620 Fax: 434-924-2932 Box 800483
Version date: 04/23/14
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