/ Institutional Review Board (IRB)

Office for Pre-Award and Compliance Services

MSC 100B - (Phone) 437-3850 (Fax) 437-3855


IRB AUTHORIZATION REQUEST

Version 01.19.17

An IRB Authorization Agreement is used when a collaborating institution is:

1.  engaged in research involving human subjects with a University at Albany investigator and

2.  only one institution's IRB will review the study to avoid the need for dual/multiple review - either the University at Albany or the collaborating institution(s).

Such a review-sharing arrangement requires a formal agreement between the institutions approved by the Institutional Signatory Official(s) or their designee(s).

Thus, this option is available only upon mutual agreement of the UAlbany Institutional Official and the Institutional Official of the external collaborating Institution.

Entering into an IRB Authorization Agreement is at the discretion of each of the collaborating institutions. Either/any of the institutions may choose not to enter into such an agreement. In such instance, multiple IRB protocols (from any of the collaborating institutions) may be required to cover the one project.

If you have questions or need assistance with this form, do not hesitate to contact the Office for Pre-Award and Compliance Services via email at or phone at 518-437-3850.

University at Albany IRB
Name / University at Albany, State University of New York
FWA # / FWA00001970
IRB Registration Number / IRB00000589
IRB Contact Name/Phone Number / Adrienne D. Bonilla, Esq. – (518) 437-3850
Institutional Signatory Official/Phone Number / Adrienne D. Bonilla, Esq. -- (518) 437-3850
Institutional Signatory Official Contact Address / Assistant VP for Research, Director
Office for Pre-Award and Compliance Services
University at Albany
1400 Washington Ave, MSC 100B
Albany, NY 12222
INSTRUCTIONS AND INFORMATION
·  This form should be completed if you wish to request an IRB Authorization Agreement with a collaborating institution.
·  Under an IRB Authorization agreement, one institution is responsible for IRB review and continued oversight for a multi-site project, precluding necessity for multiple reviewing IRBs.
·  As the Relying Institution, an Institution cedes IRB review and continuing oversight to the Reviewing Institution’s IRB.
·  In order for the Agreement to be processed and approved, the collaborating institution must have approved and on file with the Office of Human Research Protections (OHRP) a Federalwide Assurance (FWA) and (when applicable) a registered IRB.
PACS USE ONLY: Sub #
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Institutional Review Board (IRB)

Office for Pre-Award and Compliance Services

MSC 100B - (Phone) 437-3850 (Fax) 437-3855


IRB AUTHORIZATION REQUEST FORM

Version 01.19.17

1.  Principal Investigator Information
Principal Investigator
UAlbany Institutional Title
UAlbany Address
Phone
Email
2.  Sponsored Research Information
Name of Sponsor or Funding Agency
COEUS IP #
Start Date
Term Date

Will UAlbany be the Reviewing IRB Institution? NO YES

3.  Summary of research activities involving human subjects to be covered under agreement
Please be sure to Include: population(s), site(s), procedure(s), and role(s) of key personnel at each site.
4.  Collaborating Institution #1 Information
Name of Collaborating Institution (CI) #1
CI’s Federalwide Assurance (FWA) number *
CI’s IRB Registration Number **
Name of CI’s IRB Office Contact
Phone Number - CI’s IRB Office Contact
Email – CI’s IRB Office Contact
Name of CI’s Institutional Signatory Official
Required Documentation: / Copy of CI’s RB Application/ Protocol
Copy of CI’s IRB Approval
* Collaborating Institution must have OHRP registered FWA (See: http://www.hhs.gov/ohrp/assurances/assurances/index.html)
** Collaborating Institution must have OHRP registered IRB (See: http://www.hhs.gov/ohrp/assurances/irb/index.html)
5.  Collaborating Institution #2 Information (If more than 2 CI’s, please use additional page)
Name of Collaborating Institution (CI) #2
CI’s Federalwide Assurance (FWA) number *
CI’s IRB Registration Number **
Name of CI’s IRB Office Contact
Phone Number - CI’s IRB Office Contact
Email – CI’s IRB Office Contact
Name of CI’s Institutional Signatory Official
Required Documentation: / Copy of CI’s RB Application/ Protocol
Copy of CI’s IRB Approval
* Collaborating Institution must have OHRP registered FWA (See: http://www.hhs.gov/ohrp/assurances/assurances/index.html)
** Collaborating Institution must have OHRP registered IRB (See: http://www.hhs.gov/ohrp/assurances/irb/index.html)
6.  Protocol Information Check if this is UA IRB Protocol
Name of Institution
Protocol Number
Protocol Title
Principal Investigator
Items, below, to be completed ONLY If UA Protocol Principal Investigator is not same as PI in Section # 1
UAlbany Principal Investigator’s Institutional Title
UAlbany Address
Phone
Email
If UA Protocol, has UA IRB previously reviewed or approved? / NO YES If YES, UAlbany IRB Protocol #

UNIVERSITY AT ALBANY PRINCIPAL INVESTIGATOR ASSURANCE:

I acknowledge that the information provided on this form is true and accurate.

Print Principal Investigator Name / Principal Investigator Signature / Date