SUNY UPSTATE MEDICAL UNIVERSITY INSTITUTIONAL REVIEW BOARD

Request for Acknowledgement of Receipt

IRB #: Date of Request: Pri !i"a# I $esti%ator: Stu&' Coor&i ator(Co ta!t Perso : Stu&' Tit#e: Stu&' Status:
1.

a)e:

u)*er:

o"e to e ro##)e t

!#ose& to e ro##)e t

Check all items submitted: Data Mo itori % Co))ittee Re"ort +DMC, DSMBDate of re"ort Date of IB

I $esti%ator.s Bro!/ure +IB-, )ust Include Summary of Changes NCI Ce tra# IRB +stu&' re#ate& &o!u)e ts-: Ot/er +s"e!if'-:
.

!o any of the items listed abo"e necessitate a Change to the Consent !ocument#s$% Yes +note: su*)it 0it/ a amendment request form-1 If yes, /as re$ise& !o se t *ee su*)itte& to t/e IRB for re$ie02 No

&. (.

Are any sub'ects currently on study protocol%

Yes

No

)ill additional information be pro"ided to sub'ects% Yes, i !#u&e /o0 t/e i for)atio 0i## *e !o))u i!ate& to t/e su*3e!ts No, +ro"ide additional information, as needed

*.

44444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444 IR- .ffice /se .nly: Sta)" *e#o0 i &i!ates t/at t/e a*o$e ote& )ateria#s /a$e *ee re!ei$e& *' t/e
SUNY U"state Me&i!a# U i$ersit' IRB Offi!e1

5or) Versio Date: 6(76(7889

1 of 1