FORM: Dual IRB Oversight Agreement

FORM: Reliance Agreement (Dual IRB Oversight)
Document No.: / Edition No.: / Effective Date: / Page:
HRP-233 / 001 / 30 JUN 2016 / Page 1 of 2
Complete this form when a local IRB has dual jurisdiction over this research site.
You must submit a typed version of this form (except for the signature block) to prevent errors and delays due to legibility problems.
Blank & incomplete answers will result in delayed reviews
If you have questions about the use of this form, please contact WIRB at 1-800-562-4789 or email
Research Protocol:
Protocol #:
Protocol Title:
Sponsor Name:
IRB Tracking #: / (if known)
Principal Investigator:
Name:
Organization:
Name:
FWA #: / (if organization has an FWA)
Contact Information for Organization:
Name:
Title:
Address 1:
Address 2:
City: / State/Province:
Zip/Postal Code: / Country:
Phone: / Email:

Pursuant to federal regulations, Western IRB (WIRB) (IRB registration number IRB00000533) (“Central IRB”) and the Organization’s IRB agree to share oversight of the Research Protocol. Both IRBs agree to the following conditions for shared oversight:

1. If either IRB makes a finding of serious or continuing non-compliance, or suspends or terminates the research, it will notify the other IRB of these actions and provide a summary of the reasons.

2. If either IRB receives a subject complaint relevant to the oversight of the other IRB, the IRB will notify the other IRB and provide information regarding the subject complaint.

3. Both IRBs will approve the consent form, the protocol, and other aspects of the research, and both IRBs will provide continuing oversight of the research for the duration of the study.

4. Both IRBs will follow their own written procedures.

For Central IRB / For Organization
Signature / Signature
Printed Name / Printed Name
Title / Title
Date / Date