UNR-WIRB Cover Sheet and Review Authorization

Western IRB is not authorized to review UNR human subjects research activity until it has received this completed form. The box at the bottom must be completed and signed by UNR Research Integrity Office before the PI can send this form to Western IRB.

Principal Investigator (PI) Name / PI Degree and Title
PI Department or Division / PI Campus Mail Stop
PI e-mail / PI Phone
Contact person name (required) / Contact person title
Contact person phone / Contact person e-mail
Study sponsor / Sponsor’s protocol number
Clinical Trial Agreement submitted or pending through UNR OSPA Yes No
Study title

Significant Financial Interest

UNR retains the responsibility for management of financial conflict of interest in studies whose human subjects research activity is reviewed by WIRB. The following information must be complete and accurate.

Does the PI or co-investigator(s), or their families, or any other member of the research staff, or their families, have a Significant Financial Interest (value that exceeds $10,000) related to the proposed research?
Yes No
Please provide the following information for all members of the research team with a significant financial interest (SFI).
Name / Has a SFI Disclosure Form been submitted to the Office of Sponsored Projects? / Does the UNR Research Integrity Office have a copy of the Management Plan? If not, please provide it as soon as possible.
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No

Verification of Human Research Protection Training

Have all members of the research team, including all investigators and other key personnel, satisfied the University’s requirement for human research protection training?
Yes No

WIRB Fees

The University does not have the resources to pay WIRB review fees. The PI understands that if the sponsor refuses to pay WIRB fees, the PI and/or the PI’s Department will be responsible for payment of all applicable WIRB fees.
Name and Signature of Principal Investigator (required): Date
Name and Signature of Department Chair (required): Date

To be completed by UNR Research Integrity Office

Date received: / UNR-WIRB protocol number:
UNR RIO staff phone: / UNR RIO staff e-mail:
Intent to apply to WIRB acknowledged by:
Nancy Moody
Name and Signature of UNR RIO staff Date

UNR RIO 07/11/2012 version