COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH
INSTITUTIONAL REVIEW BOARD
RESEARCH PROPOSAL INFORMATION THE INVESTIGATOR PROVIDES TO THE IRB
CHECKLIST
Date:
Principal Investigator:
Revised 12/17/2010
CONFIDENTIAL
Revised 12/17/2010
Research Project Title:
Return this completed form with all appropriate documents to request DPH IRB review of a research proposal. Please check the following items. If an item does not apply to your project, indicate “not applicable.” Every item should be marked with a check mark or N/A. Note: Applications for projects applying for classification as “Exempt as Non-Research” need complete only the starred items.
1. *Application for Review of the Research Project signed by the Principal Investigator, the DPH or DHS Co-PI or Principal Liaison to the study (if the Principal Investigator is not a DPH or DHS employee) and the DPH or DHS Department Head or Program Director.
2. *Request for Exemption or Expedited Review
3. Consent forms and California Human Rights in Medical Studies
4. Professional Qualifications (curriculum vitae for new investigators and appropriate supporting information to document the investigator is qualified to conduct the research
activity).
5. Request to the IRB to Waive or Alter the Informed Consent for a Research Project
____ 6. *HIPAA Individual Authorization or Waiver Request [or N/A if no PHI involved]
7. *Protocol Detail (in summary format, not to exceed 500 -1000 words or approximately
3 word processed pages)
8. Protocol
9. Budget Detail for all proposals with funding, to include an explanation of any commitment
of County resources and in kind
__ 10. Laboratory Review Form
__ 11. *Certificate of IRB or Human Subjects Protection training, PI, co-PIs and study coordinator (unless you are certain they are already on file with the this IRB)
__ 12. Questionnaire or Script / written or verbal
13. Grant Application
14. Agreement Form for Proposals Not Involving Human Subjects or Research
15. Other (Please explain)
Revised 12/17/2010