/ FORM: Contact Information Update /
Document No.: / Edition No.: / Effective Date: / Page:
HRP-202 / 005 / 30 Apr 2018 / Page 1 of 2
Please complete this form if:
  1. A new contact is replacing a current contact,
  2. Someone on the team would like to be added as an additional contact
and/or
  1. Any of the information below for a current contact has changed and needs updating.

You must submit a typed version of this form 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 call 1-800-562-4789 or email
Today’s date:
Sponsor Name: / Sponsor Protocol #*:
Investigator Name(s): / IRB Protocol Number:
*If the below contact information needs to be updated for more than the above study or protocol, please include a list of the additional studies or protocols needing the changes:
New/Updated Contact Information
Name:
Company:
Address: / Street:
City, state, postal code, country:
Phone: / Email*:
*Study documents will be sent via e-mail to the address provided
Is the contact above replacing a current contact? / Yes* / No / NA
*If yes:
List the name of the contact you are replacing:
(WIRB staff will remove this person for the distribution list for this study)
Is the previous contact still with the company? / Yes / No* / NA
*If no, WIRB staff will update our system to eliminate him/her from our distribution list of open studies for this company
What is this new contact’s role in this study?
Sponsor* / CRO* / Study Coordinator / SMO
*If this contact is a Sponsor or CRO contact for a multi-center trial, please indicate if he/she will be the contact for allPrincipal Investigators this IRB oversees
Yes / No** / NA (not sponsor/CRO contact)
**If no, please list the names of the Principal Investigators this contact will will be the contact for:
Sponsor/CRO contacts: Is this new contact replacing the current Protocol Progress Report** contact? / Yes* / No
*If yes:
List the name of the contact being replaced:
(WIRB staff will remove this person for the distribution list for this study)
Is the previous contact still with the company? / Yes / No*
*If no, WIRB staff will update our system to eliminate him/her from our distribution list of open studies for this company
**The Protocol Progress Report (PPR) is a required Board document sent out for completion approximately 10 weeks before the expiration date of the Protocol. It is designed to collect protocol-wide information in compliance with the FDA guidance titled “Guidance for IRBs, Clinical Investigators, and Sponsor” and is not site specific.
Coordinators/SMO contacts: Is this contact replacing the current Continuing Review Report** contact? / Yes* / No
*If yes:
List the name of the contact being replaced
(WIRB staff will remove this person for the distribution list for this study)
Is the previous contact still with the company? / Yes / No*
*If no, WIRB staff will update our system to eliminate him/her from our distribution list of open studies for this company
**Continuing Review Report Forms (CRRFs) must be completed by each site and will be sent via email to the PI or previously specified CRRF Contact unless you provide an alternate name and address above.
Please provide any additional instructions/information that will help in processing your request:
Name of person completing form
Same as new contactlisted on page one.
or:
Name:
Title:
Company:
Phone: / Email:

Note: Study documents are also available on online to users who establish a Connexus®account. Don’t have a Connexus account? Click hereand select “Register Me” to set up an account.