Online Reliance Consultation Request Form

* Describe the study or studies for which reliance on a Single IRB (sIRB) is requested:
A reliance request can cover a single study or a group of studies conducted by a certain investigator or institution/organization. If you know the exact title of the study, please include it in the description. If an ERICA application has been completed, please include the IRB number.
* Provide the names of the sites (institutions and/or organizations) that are expected to be involved in this reliance request:
This should include all institutions and organizations that will need Reliance Consultation with the University of Utah Human Research Protection Program (HRPP).
* What institution/organization would you like to serve as the single IRB (SIRB) for your study?
* Are you considering any other SIRBs for this study?
Yes No Clear

* Indicate what stage/phase in the overall process the study or studies are currently:

	Stage
	Protocol development / Planning phase for a grant submission
	Ready for IRB submission and review
	Currently active protocol
	Other - please specify below
	Clear

* What are you requesting from the IRB at this point:

Request

Just in time approval/letter of support

Grant language

Fee quote

Information on the SIRB process

Other:

What is the anticipated length of the entire study, from initiation to closeout?
Include the amount of time expected to enroll participants and complete all data analysis.

* Indicate who will be the lead investigator (and/or Utah-based participating investigator) for the study or studies under this reliance request:
The lead investigator may be the Utah-based investigator.
* Provide the name and contact information for the individual(s) the University of Utah HRPP should contact to set up the Reliance Consultation meeting:
Note that an investigator involved in the study (or studies) must be included in the Reliance Consultation meeting.


*	Required