OCG Pre-IRB Funding Request Form Principal Investigator: Department: Extension: Mail Code: Email: Project Title: Project Cost Center: In accordance with the policy posted on the Division of Research website entitled Pre-IRB Spending, the department is requesting Pre-IRB spending for the above-referenced project for IRB development period: Start Date End Date Purpose Item of Cost Amount Salary & Wages: $ Fringe Benefits: $ M & O: $ Travel: $ Indirect Cost: $ Total Pre-IRB Budget $ Total Award Budget $ % budget for pre-IRB % In the event that the Pre-IRB costs on the above referenced project are not allowed by the sponsor, the charges posted to the project must be reallocated to a non-sponsored research cost center. By signing below, I certify that none of the funds nor effort charged during the development will be used for human subject research activity on this project. The funds and effort will be dedicated to protocol development and project set-up exclusively. Principal Investigator Signature of Principal Investigator Date Guarantor Signature of Guarantor/Chairman Date Compliance Specialist Signature of Compliance Specialist Date OCG Representative Signature of OCG Representative Date All expenditure documents must include the following certification statement: “I certify that none of the funds nor effort charged during the development will be used for human subject research activity on this project. The funds and effort will be dedicated to protocol development and project set-up exclusively.”
OCG Pre-IRB Funding Request Form Principal Investigator: Department: Extension: Mail Code: Email: Project Title: Project Cost Center: In accordance with the policy posted on the Division of Research website entitled Pre-IRB Spending, the department is requesting Pre-IRB spending for the above-referenced project for IRB development period: Start Date End Date Item of Cost Amount Purpose Salary & Wages: $ Fringe Benefits: $ M & O: $ Travel: $ Indirect Cost: $ Total Pre-IRB Budget $ Total Award Budget $ % budget for pre-IRB % In the event that the Pre-IRB costs on the above referenced project are not allowed by the sponsor, the charges posted to the project must be reallocated to a non-sponsored research cost center. By signing below, I certify that none of the funds nor effort charged during the development will be used for human subject research activity on this project. The funds and effort will be dedicated to protocol development and project set-up exclusively. Principal Investigator Signature of Principal Investigator Date Guarantor Signature of Guarantor/Chairman Date Compliance Specialist Signature of Compliance Specialist Date OCG Representative Signature of OCG Representative Date All expenditure documents must include the following certification statement: “I certify that none of the funds nor effort charged during the development will be used for human subject research activity on this project. The funds and effort will be dedicated to protocol development and project set-up exclusively.”