List the protocol number(s) and title(s) for the protocol(s) affected by this change: Number Title PI Name: Point of Contact for this amendment: Name Phone Number Email Name Are you Research Role Degree(s) US License Does the Note: This column only This individual will be For this study, will [Last name, First Adding or (specify individual applicable for Form B-2(s) conducting research on this individual name, email] Deleting this type of have a the following conduct research individual potential Research Activities to be institutional activities, access Example: Coordinator, license i.e., from the conflict of performed by this time/affiliation(s)?: data or store data Doe, Jane, etc.) MD, RN) doe@uthscsa.edu protocol? Note: This interest? individual at any of the (select all that To add a row should match (e.g. Obtain consent, following?: (select – select a row, copy Step 2-Inst, collect identifiable data, all sites that apply) Note: this should & paste Item 38 or Form perform procedures, match study sites To remove select B-2 maintain records, etc.) – listed in Step 1 the row & delete [Last name, First Adding Yes UTHSCSA/IIA UTHSCSA VA/WOC VA name, email] Removing No UHS UHS (If removing, do Other: not complete additional columns)
List the protocol number(s) and title(s) for the protocol(s) affected by this change: Number Title PI Name: Point of Contact for this amendment: Name Phone Number Email Name [Last name, First name, email] Example: Doe, Jane, doe@uthscsa.edu To add a row – select a row, copy & paste To remove – select the row & delete Are you Adding or Deleting this individual from the protocol? Research Role Coordinator, etc.) Note: This should match Step 2-Inst, Item 38 or Form B-2 Degree(s) US License (specify type of license i.e., MD, RN) Does the individual have a potential conflict of interest? Note: This column only applicable for Form B-2(s) Research Activities to be performed by this individual (e.g. Obtain consent, collect identifiable data, perform procedures, maintain records, etc.) This individual will be conducting research on the following institutional time/affiliation(s)?: (select all that For this study, will this individual conduct research activities, access data or store data at any of the following?: (select all sites that apply) Note: this should match study sites listed in Step 1 [Last name, First name, email] Adding Removing (If removing, do not complete additional columns) Yes No UTHSCSA/IIA VA/WOC UHS Other: UTHSCSA VA UHS
Change_Personnel.docx