Principal Investigator:
Study Title:
Institution/Hospital:
Version Date:
Vanderbilt University Institutional Review Board
PLEASE NOTE: This form may not be appropriate if this proposal is funded by a federal grant that involves human subjects for which you are the PI or the direct recipient of the grant. Consider the Application for
Coordinating Center Activities (IRB Form #1125).
Federal regulations require IRB review of all human subjects research. Some categories of research are difficult to discern as to whether they qualify as human subject research. Therefore, the IRB has established policies and
procedures to assist in this determination.
1. Study Information:
A. Give a brief synopsis of the project. If using the synthetic derivative database, insert the synthetic derivative template language along with your synopsis.
B. Describe the subject population/type of data/specimens to be studied. If using the synthetic derivative database, provide examples of ICD.9 codes or search terms that will be used.
2. Determination of “Research”.
45 CFR 46.102(d): Research means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities, which meet this definition, constitute research for purposes of this policy, whether or not they are conducted or supported under a program, which is considered research for other purposes.
A. Is this a quality improvement initiative with the intent to: (a) implement a practice to improve the quality of patient care, and/or (b) collect patient or provider data about the implementation of the practice for clinical, practical, or administrative purposes (e.g., measuring or reporting provider performance data)?
No Yes
If “yes”, this activity does not qualify as “research”, continue with question #4.
B. Is the intent of the data/specimen collection for the purpose of contributing to generalizable knowledge and of which there is a hypothesis?
No Yes
If “no”, this activity does not qualify as “research”, continue with question #4.
3. Determination of “Human Subject”.
45 CFR 46.102(f): Human subject means a * living individual about whom an investigator (whether professional or student) conducting research obtains: (1) data through intervention or interaction with the individual, or (2) identifiable private information. Intervention includes both physical procedures by which data are gathered (for example, venipuncture) and manipulations of the subject or the subject's environment that are performed for research purposes. Interaction includes communication or interpersonal contact between investigator and subject. Private information includes information about behavior that occurs in a context in which an individual can reasonably expect that no observation or recording is taking place, and information which has been provided for specific purposes by an individual and which the individual can reasonably expect will not be made public (for example, a medical record). Private information must be individually identifiable (i.e., the identity of the subject is or may be ascertained by the investigator or associated with the information) in order for obtaining the information to constitute research involving human subjects.
Determination of Non-Human Subject or Non-Research (Form #1122)
Form Revision Date: March 24, 2010
Replaces Form Dated: February 6, 2009 1 of
3

Principal Investigator:
Study Title:
Institution/Hospital:
Version Date:
A. D oes the study involve intervention or interaction with a “human subject”?
No Yes
B. Does the study involve access to identifiable private information?
No Yes
C. Are data/specimens received by the Investigator with identifiable private information?
No Yes
D. Are the data/specimen(s) coded such that a link exists that could allow the data/specimen(s) to be reidentified?
No Yes
If “ Yes ,” is there a written agreement that prohibits the PI and his/her staff access to the link?
No Yes
NOTE: A, B, and C above must be “no” in order to qualify as non-human subject.
*Answer E-G if the individual(s) is/are deceased.
E. Does the study involve use of identifiable private information?
No Yes If “No”, stop here.
Please note both the following must be “yes” to qualify for the use of the decedent’s information :
F. Is the use necessary for the purposes of the research?
No Yes
G. Does the Investigator have the documentation of the death of the individuals?
No Yes
4. Potential Conflict of Interest
A. Is there a potential conflict of interest for the Principal Investigator or key personnel?

The PI is responsible for assuring that no arrangement has been entered into where the value of the ownership interests will be affected by the outcome of the research and no arrangement has been entered into where the amount of compensation will be affected by the outcome of the research.

Assessment should include anyone listed as Principal Investigator, or other research personnel on page 1 of this application. Please note that ownership described below apply to the aggregate ownership of an individual investigator, his/her spouse, domestic partner and dependent children). Do not consider the combined ownership of all investigators.
No
Yes If “Yes”, the investigator must complete and submit IRB Form #1120, “Conflict of Interest
Supplemental Form” with this application. Form #1120 and the project must be reviewed by the VU
Conflict of Interest Committee .
NOTE: Although approval may be granted by the IRB, the Investigator may not proceed with the project until a final determination letter has been rendered by the MCCOIC or the
University Conflicts Committee.
B. If “Yes”, check all that apply :
Determination of Non-Human Subject or Non-Research (Form #1122)
Form Revision Date: March 24, 2010
Replaces Form Dated: February 6, 2009 2 of
3

Principal Investigator:
Study Title:
Institution/Hospital:
Version Date:
Compensation whose value could be affected by the study outcome.
A proprietary interest in the tested product included but not limited to, a patent, trademark, copyright or licensing agreement, or the right to receive royalties from product commercialization.
If “yes,” are these distributed through the Vanderbilt Center for Technology Transfer and
Commercialization?
No
Yes
Annual income (e.g., consulting fees, honoraria, paid authorship) and/or equity interest (e.g., stock, stock options) in the sponsor or product valued in excess of $5,000.
Any equity interest in the sponsor (e.g., stock or stock options, founders’ share) if a non-publicly traded company.
Determination of Non-Human Subject or Non-Research (Form #1122)
Form Revision Date: March 24, 2010
Replaces Form Dated: February 6, 2009 3 of
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