Delegation of e-Signature This form can be used to document the delegation of e-Signature authority for IRB applications and submissions. Name of Person who is authorizing the delegation: Role(s) of Person who is authorizing the delegation (check all that apply: Department Head (e.g., Department Chair, Dean) Principal Investigator Department Representative (e.g., Ancillary Reviewer) Other Signatory: specify: Name of Person who is delegated authority to e-sign on behalf of the above person: Title of Person who is delegated authority to e-sign on behalf of the above person: Check at least one box below to designate authority or limitations of delegated authority below: No Limitations (full authority) Delegated authority is limited to a specific study. Specify IRB Number: Delegated authority is limited to specific submission types. Specify types: Amendments to change study staff Exempt submissions Expedited submissions Full board submissions Administrative submissions Other: specify: Other Comments: Date Authorized: Expiration Date (if any:) Signature of Person who is authorizing the delegation: ___________________________ Please sign and send to or FAX to (718) 613-8497
Delegation of e-Signature This form can be used to document the delegation of e-Signature authority for IRB applications and submissions. Name of Person who is authorizing the delegation: Role(s) of Person who is authorizing the delegation (check all that apply: Department Head (e.g., Department Chair, Dean) Principal Investigator Department Representative (e.g., Ancillary Reviewer) Other Signatory: specify: Name of Person who is delegated authority to e-sign on behalf of the above person: Title of Person who is delegated authority to e-sign on behalf of the above person: Check at least one box below to designate authority or limitations of delegated authority below: No Limitations (full authority) Delegated authority is limited to a specific study. Specify IRB Number: Delegated authority is limited to specific submission types. Specify types: Amendments to change study staff Exempt submissions Expedited submissions Full board submissions Administrative submissions Other: specify: Other Comments: Date Authorized: Expiration Date (if any:) Signature of Person who is authorizing the delegation: ___________________________ Please sign and send to or FAX to (718) 613-8497
Delegationofe-signature04.14.2017.docx