Institutional Review Board (IRB) Authorization Agreement

Name of Institution or Organization Providing IRB Review (Institution/Organization A):
___________________________________________________________________________________ 

IRB Registration #: ________________ Federal-wide Assurance (FWA) #, if any: _________________

Name of Institution Relying on the Designated IRB (Institution B):
___________________________________________________________________________________     

FWA #: _____________________

	The Officials signing below agree that        (name of Institution B)      may rely on the designated IRB for review and continuing oversight of its human subjects research described below:  (check one)

(___) This agreement applies to all human subjects research covered by Institution B’s FWA.

(___) This agreement is limited to the following specific protocol(s):

          Name of Research Project:________________________________________________________
          Name of Principal Investigator:_____________________________________________________
          Sponsor or Funding Agency: ________________ Award Number, if any: ___________________

(___)  Other (describe):________________________________________________________________

The review performed by the designated IRB will meet the human subject protection requirements of Institution B’s OHRP-approved FWA.  The IRB at Institution/Organization A will follow written procedures for reporting its findings and actions to appropriate officials at Institution B. Relevant minutes of IRB meetings will be made available to Institution B upon request.  Institution B remains responsible for ensuring compliance with the IRB’s determinations and with the Terms of its OHRP-approved FWA.  This document must be kept on file by both parties and provided to OHRP upon request.

Signature of Signatory Official (Institution/Organization A):
________________________________________  				Date: ___________

Print Full Name:  ________________________________ Institutional Title: _____________________

NOTE: The IRB of Institution A must be designated on the OHRP-approved FWA for Institution B.

Signature of Signatory Official (Institution B): 
________________________________________  				Date: ___________

Print Full Name:  ________________________________ Institutional Title: _____________________