Requests for the Cook County Health & Hospitals System (CCHHS) Institutional Review Board (IRB) to formally agree to rely upon IRB review and approval by another academic or non-profit IRB is determined on a case by case basis, involving CCHHS legal and compliance office review as needed. Process initiation must be led by a responsible CCHHS Principal Investigator (PI) and begins with the satisfactory completion of this form. Initial inquiries for such agreements that are not led by the CCHHS PI will not be considered. Please Attach Proposed Reliance Agreement for Review Please indicate by [X] if the proposed agreement is to serve for one study, or multiple studies here: One ____ Multiple_____ Reviewing Institution Name: Reviewing Institution Principal Investigator Name: (Initial) Title: Study Abstract: (Please attach full protocol proposal, accompanying documents, including consent language, if available) Study Sponsor: CCHHS Principal Investigator Last Name: CCHHS Principal Investigator First Name: CCHHS Affiliate/Department/Division Name: CCHHS Affiliate/Department/Division Head Name: PI Contact Information: Email address: __________________________________________ Office address: ______________________________________________ Telephone number: _____________________________________ Pager/Cell number: __________________________________________ My signature below represents a committed pledge to: Take responsibility for administrative and ethical implementation of any and all studies associated with this agreement within CCHHS in terms of human subject/participant protection.
Requests for the Cook County Health & Hospitals System (CCHHS) Institutional Review Board (IRB) to formally agree to rely upon IRB review and approval by another academic or non-profit IRB is determined on a case by case basis, involving CCHHS legal and compliance office review as needed. Process initiation must be led by a responsible CCHHS Principal Investigator (PI) and begins with the satisfactory completion of this form. Initial inquiries for such agreements that are not led by the CCHHS PI will not be considered. Please Attach Proposed Reliance Agreement for Review Please indicate by [X] if the proposed agreement is to serve for one study, or multiple studies here: One ____ Multiple_____ Reviewing Institution Name: Reviewing Institution Principal Investigator Name: (Initial) Title: Study Abstract: (Please attach full protocol proposal, accompanying documents, including consent language, if available) Study Sponsor: CCHHS Principal Investigator Last Name: CCHHS Principal Investigator First Name: CCHHS Affiliate/Department/Division Name: CCHHS Affiliate/Department/Division Head Name: PI Contact Information: Email address: __________________________________________ Office address: ______________________________________________ Telephone number: _____________________________________ Pager/Cell number: __________________________________________ My signature below represents a committed pledge to: Take responsibility for administrative and ethical implementation of any and all studies associated with this agreement within CCHHS in terms of human subject/participant protection.
Reliance-Agreement-Form-Final-4-19-17.docx