NUS Institutional Review Board (IRB)

EXEMPTION FROM FULL IRB REVIEW FORM

Please refer to IRB-Guide-006-RESEARCH WHICH CAN BE EXEMPTED FROM FULL IRB REVIEW, before completing this form.
1Protocol Title
2 Study / Site(s) of Research(Dept. and Institution):______
* Single-Centre / Singapore Multicentered / International Multicentered
If single-centered, has a similar study been conducted elsewhere? * Yes / No
If Yes, state where : ______
Previous Ethics Committee submission? * Yes / No
(If yes, please provide details separately.)
3. Type of Study / (Please refer to our Guidelines On Which Research Can Be ExemptedFrom IRB Review - IRB-Guide-006)
Educational settings research, educational tests or instructional techniques and methods
Survey without identifiers
Analysis of publicly available data or dataset stored without identifiers
Commercial cell lines, tissues, anonymous biological samples, body parts (please see table below)
Type of Human Tissues / Name of Human Cell Lines
(e.g. HeLa) / Source & Catalog No. (e.g. ATCC, CCL-2) / Indicate if tissues / cell cultures are: (Please tick)
Primary / Secondary
(Please attach separate sheet, if required)
4Financial Declaration / This study is initiated by the * Investigator / Commercial/Pharmaceutical Company
Source of funding for study : ______
Amount of Sponsorship / Grant : ______Status of grant: Approved / Pending/ Not applicable
Financial benefits to Subjects (if any) :______
The financial benefits or other benefits derived from this study to PI / Co-investigators / Department / Institution are as follows: ______
(Please provide a copy of the financial agreement with sponsor company, if applicable.)
5Documents Checklist / Mandatory (Please submit the following documents.)
Protocol/Proposal
Catalog details ORproof of purchase of cell lines, if applicable
List of PI & co-investigators with their signatures, together with their CVs
6 Declaration
This Research Proposal has the approval of the Head/Chief of Department.
Signature of Head of Department : Date :
Name of Head of Department :
I confirm that the information submitted in this application is correct and I will conduct the study in accordance with the IRB-approved protocol, IRB requirements/policies, and all applicable rules and regulations.
Signature of Principal Investigator : ______Date : ______
Name of Principal Investigator : ______Contact Number : ______
Department / Institution : ______Email : ______
* Please circle accordingly. This is a 1-page form on A4 paper. Misalignment should be adjusted accordingly.
Please submit this form with the protocol and other documents to apply for exemption from IRB review. Thank you.

IRB-FORM-008Page 1 of 1Version No: 3.3

Date of revision: 14/10/08