University of Pittsburgh
Education and Compliance Office for Human Subject Research
IND and IDE Fee Information Sheet
Sponsor:Principal Investigator:
Division/Department:
IND or IDE Number:
Protocol Title:
Protocol IRB Number:
Sponsoring Agency:
Date:
University 32-Digit Account Number:
Please Check Payment Type Below:[ ] / New Protocol – $3000 / [ ] / Annual Report – Continuing $1500
Administrative Contact Information
Name:Phone Number:
FAX Number:
e-Mail Address:
Authorized Signature:
Please make checks payable to:
University of Pittsburgh
Education and Compliance Office for Human Subject Research
Suite 204
3500 Fifth Avenue
Pittsburgh, PA 15213
Attn: Angie Coldren
Fax: 412-383-1388
If you have any questions, please contact Angie Coldren: 412-383-1712 or