The purpose of this checklist is to have IRB members provide information to the IRB staff to ensure the IRB is appropriately composed. This form should be completed and retained. First name: Last name: List all earned degrees: Mailing address: Office phone: Cell phone: Fax: Home Email: List the vulnerable populations Children Pregnant women Other: (specify) you are knowledgeable about or Prisoners Cognitively impaired experienced in working with: Disabled Economically disadvantaged Provide indications of experience such as profession, life experiences related to research or vulnerable populations, research experience as an investigator or subject, IRB experience, certifications and licensures, or other information sufficient to describe your chief anticipated contributions to IRB deliberations: List any employment or other relationship between yourself and the organization or its affiliates: No affiliation Paid or unpaid consultant Retiree Full-time employee Medical staff Other: (Specify) Part-time employee Full or part-time faculty Affiliation is with: Member of governing panel or board Student This organization. Stockholder Intern, resident, or fellow Affiliated organization: (Specify) List any employment or other relationship between your spouse/domestic partner and dependent children and the organization: Full-time employee Paid or unpaid consultant Intern, resident, or fellow Part-time employee Medical staff Retiree Member of governing panel or board Full or part-time faculty Other: (Specify) Stockholder Student Signature: Date:
The purpose of this checklist is to have IRB members provide information to the IRB staff to ensure the IRB is appropriately composed. This form should be completed and retained. First name: Last name: List all earned degrees: Mailing address: Office phone: Cell phone: Fax: Home Email: List the vulnerable populations you are knowledgeable about or experienced in working with: Children Prisoners Disabled Pregnant women Cognitively impaired Economically disadvantaged Other: (specify) Provide indications of experience such as profession, life experiences related to research or vulnerable populations, research experience as an investigator or subject, IRB experience, certifications and licensures, or other information sufficient to describe your chief anticipated contributions to IRB deliberations: List any employment or other relationship between yourself and the organization or its affiliates: No affiliation Full-time employee Part-time employee Member of governing panel or board Stockholder Paid or unpaid consultant Medical staff Full or part-time faculty Student Intern, resident, or fellow Retiree Other: (Specify) Affiliation is with: This organization. Affiliated organization: (Specify) List any employment or other relationship between your spouse/domestic partner and dependent children and the organization: Full-time employee Part-time employee Member of governing panel or board Stockholder Paid or unpaid consultant Medical staff Full or part-time faculty Student Intern, resident, or fellow Retiree Other: (Specify) Signature: Date: