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RequirementsFor UCB to review for an Individual Investigator, please affirm that ONE of the following is true:? Non-UCB researchers do NOT have a potential financial Conflict of Interest associated with the research.Individual InvestigatorInvestigator Name:Click or tap here to enter text.Email:Click or tap here to enter text.ProjectProject Title:Click or tap here to enter text.Reviewing IRB Protocol Number:Click or tap here to enter text.Funding Source (Insert or attach additional)UCB Recipient StatusSPO Award#Click or tap here to enter text.? Prime ? Sub ? NoneClick or tap here to enter text.Click or tap here to enter text.? Prime ? Sub ? NoneClick or tap here to enter text.Click or tap here to enter text.? Prime ? Sub ? NoneClick or tap here to enter text.Click or tap here to enter text.? Prime ? Sub ? NoneClick or tap here to enter text.Is UCB the prime recipient of a federal award in which all human subjects activities will be carried out by employees or agents of another institution?? Yes? NoUCB InvestigatorsPrincipal Investigator:Click or tap here to enter text.Co-/Student Investigator (if applicable):Click or tap here to enter text.RolesBriefly describe the respective roles of the individual and UCB investigators (such as research design, recruitment, obtaining consent, administering interventions, or analyzing identifiable data), including where they will take place:Click or tap here to enter text.Agreement by UCB Principal InvestigatorThe UCB Principal Investigator agrees to comply with all requirements and expectations described in UCB’s IRB Reliance Policy and UCB Guidance on Reliance Agreements for Non-UC Collaborations.Click or tap here to enter text.Principal Investigator’s SignatureDate ................
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