Recruitmentand Study MaterialSubmission Cover Page

Submit cover page directly to Quorum Review IRB.

Attach additional pages as necessary.
1601 Fifth Ave., Ste.1000, Seattle, WA 98101

Phone (206) 448-4082 Fax (206) 448-4193

Date / Submitted by
Sponsor / Phone
Protocol Number / Quorum Review Number
Principal Investigator / Site/Center Name
Please choose one option:
This material is being submitted on behalf of the Principal Investigator listed above.
This material is being submitted on behalf of all Investigators for the protocol listed above.
This material is being submitted on behalf of some Investigators for this protocol. PLEASE ATTACH LIST.
This material is being submitted for use by the sponsor/CRO at the national or regional level.
*Please see Guide to Participant Recruitment for information on this type of material.
Please choose one option:
This material has not yet been submitted to Quorum Review IRB.
This material is being resubmitted with Quorum-requested modifications.
This material has been received by Quorum Review IRB for this protocol or site before and is being resubmitted with revisions to the Quorum-approved version.*
This material has been approved by Quorum Review IRB for another protocol or site with this sponsor.* QR# ___
*For previously approved material and recordings based on previously approved scripts, please include a copy of the material with the Quorum-approved stamp for our reference. Quorum Review IRB reserves the right to request additional changes to previously approved material.
Does this material require translation? Y N
If yes, what language(s)?
Is this material referenced in the Protocol? Y N
If yes, what section/page?
Does this material require Sponsor Approval? Y N
If yes, please provide written documentation from Sponsor/CRO
*Most advertisements require Sponsor Approval. If you are unsureabout whether or not this study requires Sponsor Approval,contact Quorum or your sponsor representative for assistance. Ads submitted without required Sponsor Approval will experience a delay.
Title of Material / Type of Recruitment or Participant Study Material / Where will the material be published or used?
(local newspaper name, magazine name, location of posting, etc.
Recruitment Material / Study Material
Newspaper / Poster/Flyer / Brochure / Press release / "Dear Participant" Letters / Informational Article / Radio Script or Recording / Public Service Announcement script or recording / Phone Screen / Website / Internet Screen / Gift* / Diary / Questionnaire / Survey / Medical Guidelines / Study Instructions / Other/General Use:______
Study Procedures / Device / Diet
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2.
3.

* All gifts should be submitted to Quorum Review for review. The provision of gifts may need to be incorporated into the Quorum-approved consent form.

F-046.02, Participant Recruitment Material Submission Cover Page, 06/08/2009Page 1 of 1