01/09
IRB Office
Suite 100 Jewett
(208)495-5600
Fax (208) 459-5043  	

Social-Behavioral-Educational Research
Request for Modification to a Currently Approved Study

Date:__________________

Project Director:
	
Phone:			Fax:
	
Campus Box or Address:
	
Email:

Faculty Sponsor:
	
Phone:			Fax:				Campus Box:
	
Email:

Administrative Contact: (if applicable)
	
Phone:			Fax:				Campus Box:
	
Email:

Project Title:

IRB #:	

I assure that the requested changes will not be initiated without IRB approval, except when necessary to eliminate apparent immediate hazards to research participants.

	  
 Project Director Signature	Date	

	  
 Faculty Sponsor Signature	Date

For IRB use		                                                                  MODIFICATION APPROVED

 Signature of Chair (or designee)				                     Date:

1.	Does your modification involve only changes to the project team?       Yes     No **

2.	Does your modification involve only changes to the funding source (e.g, adding or deleting a grant award)?                                                                                         Yes     No **
Attach a copy of the entire grant application (excluding appendices) and the Research Office Proposal Certification (PC) cover sheet, if available.  Block out salary information.  Note: The  IRB is required by the federal Office of Human Research Protection (OHRP) to review the entire grant application and human research protocol for consistency.  You may be asked to explain discrepancies, if any, identified by IRB during the review process.

Please complete the boxes below.
Name of Agency/Funding 
Source (e.g., NIH, NSF)	Grant or Identifying
Number	Grant Title if different from Project  Title (if applicable)	Status (Awarded/Pending)	

** Unless your modification involves only the addition or deletion of project team members or change in funding source, it will be necessary to include an updated version of your project proposal (protocol), with the changes highlighted (no matter how small). The IRB is required by federal regulations to have current protocols of all approved research involving human participants.

3.	All Other changes.

Describe requested change(s).	Indicate the affected Documents
(consent, protocol, etc.)
Highlight all changes	

		

4.	Are any changes being made because of new information or participant experiences that might affect the risk/benefit ratio and/or an individual’s willingness to participate in your study?
	  No  
	  Yes  Provide explanation on a separate page.

5.	Are there any changes to the consent form previously approved by the IRB (including changes to compensation, time required, or individuals to be contacted)?
	  No  
	  Yes  Include a copy of the revised consent document with this application.
	
Investigator’s Statement of Financial Conflict of Interest
Does the Project Director* or any individual* involved in the design, conduct, or reporting of the research have, or anticipate having, any income from or financial interest in: the sponsor of the protocol, the supporting organization, or the company that owns/licenses the technology being studied?               
Yes	  No

*Financial interest includes but is not limited to: consulting, speaking or other fees; honoraria, gifts; licensing revenues; other research agreements; equity interests; or stock options.