human subjects research determination request exemption ：人体研究确定请求豁免

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1、HumanSubjectsResearchDeterminationRequestExemptionDeterminationRequestTypeofRequest(Pleasecheckallthatapply):ExemptionDeterminationRequestand/orHumanSubjectsResearchDeterminationRequestThankyouforchoosingQuorumReviewtoreviewyourHumanSubjectsResearchDetermination

2、and/orExemptionRequest.Ifyouhaveanysubmissionquestionsthatarenotansweredonthispage,pleasecontactInitialStudySupportat(206)448-4082orInitialStudySupport@quorumreview.com.SUBMISSIONINSTRUCTIONSSubmissionsmaybemadeelectronicallythroughtheQuorumWebPortalorbyemailtoI

3、nitialStudySupport@quorumreview.com.HardcopysubmissionsmaybesenttoQuorumReview,1601FifthAvenue,Suite1000,SeattleWA98101.Toensurepromptreviewpleaseincludethefollowingmaterials:·Onecopyofthefinalprotocolorresearchproposal·InstitutionalJurisdictionWaiverForm,ifappl

4、icable.PARTI:GENERALINFORMATIONF-118-003,HumanSubjectsDeterminationRequest/ExemptionDeterminationRequest,2011-Sep-26Page10of10HumanSubjectsResearchDeterminationRequestExemptionDeterminationRequest1.1GENERALSTUDYINFORMATIONResearcher/PrincipalInvestigator:Protoco

5、lNumber:ProtocolTitle:FundingAgency(ies)and/orSponsorname:GrantNumber:1.2STUDYCONTACTINFORMATIONPrimaryContact:Forphonecalls,documents,andcorrespondence.ThroughtheQuorumWebPortal,primarycontactscanaccessstudydocuments.Pleasecheckappropriatebox:SPONSOR/CROINVESTI

6、GATIVESITEOTHER(pleasespecify):Name:Title:Company:MAILINGADDRESSforallstudy-relatedcorrespondenceAddress:F-118-003,HumanSubjectsDeterminationRequest/ExemptionDeterminationRequest,2011-Sep-26Page10of10HumanSubjectsResearchDeterminationRequestExemptionDeterminatio

7、nRequestCity:State/Province:Zip/Postalcode:Country:Phone:Fax:Email:Website:PHYSICALADDRESS(ifdifferentthanabove)Address:City:State/Province:Zip/Postalcode:Country:SecondaryContact:AsecondarycontactcanreceivehardcopiesofallBoardcorrespondence(includingapprovaldoc

8、uments),orcanaccessthosedocumentsviatheQuorumWebPortal.Pleaseprovidehardcopiesofalldocumentstothiscontact.PleaseprovideQuorumWebPortalaccessonly.Pleasecheckappropriat