Notices and Primary Contacts. Any notices that are sent to the undersigned institutional officials or correspondence regarding IRB review and oversight, or any other notices required under this Agreement, must be addressed as follows: Designated Institutional Review Board Primary Contact: Name: Xxxxxxx Xxxxx, MA, CIP Title: Associate Director, Regulatory Affairs and Reliance Address: 0000 XX 00xx Xxxxxx (X-000), Xxxx 0000, Xxxxx, XX 00000 Email: xxxxxx@xxx.xxxxx.xxx Phone: 000-000-0000 Relying Institutions Primary Contact: Name: ______________ Title: ______________ Address: ______________ Email: ______________ Phone: ______________ Termination
Notices and Primary Contacts a. Any correspondence regarding this study should be addressed to: Relying Institution: Metrocare Services Name: Xxxxxx Xxxxxx Title: Metrocare Services IRB Chair Address: 0000 Xxxxxxxxx Xxxxx, Xxx. 000, Xxxxxx, XX 00000 Email: xxxxxxxxxxxx@xxxxxxxxxxxxxxxxx.xxx Phone: (000) 000-0000 Reviewing Institution: [Insert IRB of Record Here] Name: Title: Address: Email: Phone: This agreement will become effective upon the date of the last signature by the institutional officials below and will remain in effect until the termination of the research study listed in Part II or until such time that either institution provides 30 days written notice of termination to the other institution. Signature of Signatory Official for [Insert IRB of Record Here]: Signature: Date: Print Full Name: Institutional Title: Signature of Principal Investigator: Signature: Date: Print Full Name: Co-Principal Investigator/Advisor: Date: Print Full Name: Signature of Signatory Official for Metrocare: Signature: Date: Print Full Name: Institutional Title: Signature of Signatory for Metrocare Services IRB Chair: Signature: Date: Print Full Name: Institutional Title:
Notices and Primary Contacts
