For HSR office use only
Receipt Date:
INSTRUCTIONS AND INFORMATION
IMPORTANT: Please make every effort to locate documents needed before completing this form and asking for new copies.
A request for a large volume of copies or frequent copies may lead to a PAM audit.
· This form can be e-mailed to , faxed to 4-2932, sent via Messenger Mail to Box 800483, or dropped off at Davis 5, Room 5293.
· The person requesting the information MUST currently be on the study team.
· Copies are typically made by staff on Wednesdays.
· Researchers are not allowed to make their own copies.
· If you are requesting a large volume of copies you will be expected to bring paper to the IRB office for the copying.
· Copies will then be sent out to you per the manner you select on this form.
IRB-HSR #: / PI Name:SELECT ITEM(S) BELOW THAT YOU NEED COPIED
Current consent / Version date:
Current HSR Protocol / Version date:
Most recent continuation approval form / Date of event:
Most recent modification approval form / Date of event:
Original approval form / Date of event:
Other (specify)
CONTACT INFORMATION
Contact Name:
(this is the person who will receive the copies) / Phone Number:
E-mail address: / Messenger Mail:
ROUTE FOR RETURNING COPIES
Return reply in messenger mail
I will pick up reply at Davis pick-up box
I will pick up reply from Morton Drive
Comments:
If a reply is not picked up within 5 weekdays the reply will be sent to contact via Messenger Mail.Copies Completed and Sent : Date
IRB-HSR Staff Member ______
Website: http://www.virginia.edu/vpr/irb/hsr/index.html
Phone: 434-924-2620 Fax: 434-924-2932 Box 800483
Version date: 11/15/12
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