Additional PI Name PI Status? Contact Information Description of the roles, responsibilities and the working relationship to the primary PI. Downstate Faculty Member Phone # KCHC Employee with Email : Clinical Privileges Other. Specify: Downstate Faculty Member # KCHC Employee with Email : Clinical Privileges Other. Specify: Downstate Faculty Member # KCHC Employee with Email : Clinical Privileges Other. Specify: Note: Attach additional sheets if needed. The first PI listed in the IRB application must be affiliated with the Downstate or KCHC and will serve as the contact PI. Each PI must electronically sign the initial submission. If adding staff (even if listed in response to question E), complete the following chart with the new staff member’s information (If additional space is needed, please continue on a separate page using the same format): a. b. c. d. e. f. Name & degree Role(s) on Project. Examples: Will this person be Is this person an Will this person aid the Place of employment Principal Investigator, obtaining verbal or for the “Investigator shipment of hazardous Coordinator, Consultant, written Informed purposes of COI materials (e.g., Fellow, Resident, Student, Research Consent/Authorization reporting”? dangerous goods, Staff, Healthcare Operations only, THE PI IS ALWAYS specimens) to be Access to de-identified data only, CONSIDERED AN transported by a public Specimen shipment, etc. INVESTIGATOR FOR COI carrier? PURPOSES.
Additional PI Name PI Status? Contact Information Description of the roles, responsibilities and the working relationship to the primary PI. Downstate Faculty Member KCHC Employee with Clinical Privileges Other. Specify: Phone # Email : Downstate Faculty Member KCHC Employee with Clinical Privileges Other. Specify: # Email : Downstate Faculty Member KCHC Employee with Clinical Privileges Other. Specify: # Email : Note: Attach additional sheets if needed. The first PI listed in the IRB application must be affiliated with the Downstate or KCHC and will serve as the contact PI. Each PI must electronically sign the initial submission. If adding staff (even if listed in response to question E), complete the following chart with the new staff member’s information (If additional space is needed, please continue on a separate page using the same format): a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier?
ApplicationforAmendment2018.03.14.docx