University Committee on Human Subjects (UCHS)

Revision: 10/19/05

REQUEST TO AMEND

A PREVIOUSLY-APPROVED PROJECT

CORNELL UNIVERSITY

University Committee on Human Subjects (UCHS)

Please click in shaded fields to enter information

Project Identification:

Title of Research Project (use same title under which project was approved)

Protocol ID# (found on latest approval letter): - -

Investigator's Name:

Campus Address:

Investigator's Signature:

Signature of faculty member supervising project (if applicable):

Date of request:

Anticipated End Date of Project:

Information on Amendments

1. What type(s) of amendment(s) are you requesting? Please describe in detail.

2. Briefly describe the reason(s) you are making amendment(s) to the study.

3. Are any of these changes the result of something that occurred during human subject interaction? Yes No

If Yes, please describe the event(s):

4. Are you submitting, for UCHS approval, revisions of or new study interviews, questionnaires, study guides, or debriefing forms? Yes (please attach) No

5. Are you submitting, for UCHS approval, final forms of study protocols that were reviewed in draft form?

Yes (please attach) No

6. Are you submitting, for UCHS approval, a revised version of or a new informed consent document or procedure?

Yes (please attach) No

7. Are you submitting, for UCHS approval, any other change in study procedures, such as design, designation of principal investigator, change in the recruitment techniques, etc.? Yes No

If Yes, please describe those changes and attach documentation (as necessary).