The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

yrowBpgJkGtuD3og7xDWHALSPpdZNyFefPbRQSvw5pAiC8EMo2GM3ASubxNteP9EvqDo64xUkCkQc76uP7K7ewoL5DmFHVnFDs7VtdW3T9wDycsJYs4H

Request Form

Please complete the request form below to begin the concurrence process for OU to serve as IRB of record for non-OU sites.

Note: If one or more of the non-OU sites do not have an IRB of their own, do not submit this form! Call the HRPP Office at 271-2045, email SIRB@ouhsc.edu, or visit our website to complete an individual investigator agreement.

IRB #

* must provide value

Study Title

* must provide value

OUHSC PI

* must provide value

How many sites are requesting that OUHSC IRB serve as the IRB of record?

* must provide value

**SITE 1**
Name of site 1

______ PI

IRB Contact for ______ (name, email address & phone number):

Expand

______'s Federalwide Assurance (FWA) number:

Is ______ apart of the SMART IRB master reliance agreement network?

Yes

reset

Is ______ requesting for OUHSC to serve as the Privacy Board?

Yes

reset

**SITE 2**
Name of site 2

______ PI

IRB Contact for ______ (name, email address & phone number):

Expand

______'s Federalwide Assurance (FWA) number:

Is ______ apart of the SMART IRB master reliance agreement network?

Yes

reset

Is ______ requesting for OUHSC to serve as the Privacy Board?

Yes

reset

**SITE 3**
Name of site 3

______ PI

IRB Contact for ______ (name, email address & phone number):

Expand

______'s Federalwide Assurance (FWA) number:

Is ______ apart of the SMART IRB master reliance agreement network?

Yes

reset

Is ______ requesting for OUHSC to serve as the Privacy Board?

Yes

reset

**SITE 4**
Name of site 4

______ PI

IRB Contact for ______ (name, email address & phone number):

Expand

______'s Federalwide Assurance (FWA) number:

Is ______ apart of the SMART IRB master reliance agreement network?

Yes

reset

Is ______ requesting for OUHSC to serve as the Privacy Board?

Yes

reset

**SITE 5**
Name of site 5

______ PI

IRB Contact for ______ (name, email address & phone number):

Expand

______'s Federalwide Assurance (FWA) number:

Is ______ apart of the SMART IRB master reliance agreement network?

Yes

reset

Is ______ requesting for OUHSC to serve as the Privacy Board?

Yes

reset

The following documents are required.

Protocol

* must provide value

Upload file

Draft consent form

Upload file

Provide any additional information here.

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