UCLA Office of Human Research Protection Program (OHRPP)

Application for UCLA to Serve as IRB of Record for Individual Study

APPLICATION FOR UCLA TO SERVE AS IRB OF RECORD - INDIVIDUAL STUDY REQUEST

INSTRUCTIONS FOR USE: UCLA IRB approval for research conducted in collaboration with other institutions/agencies constitutes IRB approval for the non-UCLA institutions only when the UCLA IRB has formalized a written agreement to be the designated IRB for the collaborating institution. See UCLA OHRPP Relying on Other IRBs for additional details.

Email the completed form to:

UCLA Study Title: / UCLA webIRB Protocol ID: / Reviewing IRB
NGIRB MIRB1
SGIRB MIRB2
Exempt MIRB3

UCLA Principal Investigator:

Name and degree / Department / E-mail Address
Contact Person:
Name / Department / E-mail Address
Funding Source(s): / Primary Awardee
Federal Government - Specify:
Other - Specify: / UCLA
Collaborator named in this application
Other - Specify:
Institution Requesting to Rely on the UCLA IRB (complete separate form for each institution)
Does the institution have an IRB?
Yes * No
* If yes, provide the name and email address of the collaborating institution’s IRB representative
List the investigators at the Collaborating Institution (names and degrees)
Name(s) / Degree(s) / E-mail Address
Describe the Collaborating Institution/Investigator(s)’s role in the research.
Describe the UCLA investigator’s ongoing oversight of the research activities conducted at the non-UCLA institution, and/or by the non-UCLA institution’s personnel
UCLA Principal Investigator's Certification::
·  I certify that the information provided in this application is complete and correct.
·  I certify that I will follow my IRB Approved Protocol.
·  I accept ultimate responsibility for the conduct of this study, the ethical performance of the project, and the protection of the rights and welfare of the human subjects who are directly or indirectly involved in this project.
·  I will comply with all applicable federal, state and local laws regarding the protection of human subjects in research.
·  I will ensure that the personnel performing this study are qualified and adhere to the provisions of this IRB-certified protocol.
UCLA Principal Investigator's Signature / Date

******************************************************************************************UCLA OHRPP Determination

Minimal Risk Research: UCLA OHRPP Determination
UCLA IRB will serve as IRB of record for collaborator named in this application / Yes
No
Not required because:
Collaborator is not engaged
Other (explain below)
UCLA OHRPP risk assessment / Minimal risk
More than minimal risk
Authorized UCLA OHRPP Signature / Date
More than Minimal Risk Research: UCLA Institutional Official Authorization
Vice Chancellor for Research / Designee / Date

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