97 Attachment B49 Incarcerated Participant Wrksht

0MB #: 0925-0753

Expiration Date: 07/31/2021

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STATEMENT OF CONFIDENTIALITY
The purpose of the information collection
conduct reviews of clinical trial studies. NCI guidelines mandate the participation of
institutions in the CIRB for Network group studies. You are being requested to complete this instrument so that we can conduct
activities involved with the operations of the NCI CIRB Initiative. Although your participation in rietwork group research and
completion of the forms is voluntary, if you wish to participate in the CIRB, you must complete all questions on the form. The
information you provide will be combined for all participants and reported as summaries. It will be kept private to the extent
provided by law.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 20 n1inutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid 0MB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA {0925-0753). Do not return the completed form to this address.

Signatory Institution Information

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1. Submitting User Information
Name
Email:

Business Phone:

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L l:nter the study JU Number. (<.;lick here if you would like to review a list of studies currently covered by NCJ LIKH)
(Required)

3. Enter the email address of the Investigator providing this notification

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4. Signntnry Jnstitntion

IC:RB Operations Office • I
:,, tilter the study l'articipant Kegistration rwml>er or another uniQue anonymous ic:lentifier for participant.
I here should be a separatec:I worksheet for each participant anc:I study impacted.

(Requi:-ed}