4. Research Coordinator (name): E-mail: Pager Number/Cell Phone Number: Section 2 Requested –Change 5. Please check requested change and complete applicable section(s): Removal of Study Staff Addition of Study Staff Section 3 Removal of Study Staff – 6. List Study Staff being removed Name Role in Study (Use the enter key to insert additional names and information) Section 4 Addition of Study Staff – 7. List the name and role of study staff to be added that have access to identifiable and/or sensitive data and study documents. Study Staff Name Study Staff Role IRB OFFICE ONLY HSP & CREDENTIALING Use the enter key to insert VA Research Education additional names and CHECKED Date Completed information Study Staff Agreement I acknowledge my role in this research study and I agree to adhere to applicable federal research regulations and LSCDVAMC policies and procedures relative to the protection of the rights and welfare of the subjects enrolled in this study. Name (typed) Date Signature 8. Co-investigators only submit a Signed Conflict of Interest Statement 9. Please check as applicable and attach documents Revised Informed Consent Form and/or Research Plan Revised VA Form 10-9012 Investigational Drug Information Record reflecting change in study staff that have prescriptive authority
4. Research Coordinator (name): E-mail: Pager Number/Cell Phone Number: Section 2 –Change Requested 5. Please check requested change and complete applicable section(s): Removal of Study Staff Addition of Study Staff Section 3 – Removal of Study Staff 6. List Study Staff being removed Name (Use the enter key to insert additional names and information) Role in Study Section 4 – Addition of Study Staff 7. List the name and role of study staff to be added that have access to identifiable and/or sensitive data and study documents. Study Staff Name Use the enter key to insert additional names and information VA Research Education Date Completed Study Staff Role IRB OFFICE ONLY HSP & CREDENTIALING CHECKED Study Staff Agreement I acknowledge my role in this research study and I agree to adhere to applicable federal research regulations and LSCDVAMC policies and procedures relative to the protection of the rights and welfare of the subjects enrolled in this study. Name (typed) Date Signature 8. Co-investigators only submit a Signed Conflict of Interest Statement 9. Please check as applicable and attach documents Revised Informed Consent Form and/or Research Plan Revised VA Form 10-9012 Investigational Drug Information Record reflecting change in study staff that have prescriptive authority
Study_Staff_Change.docx