Fields marked with a * are required.
1) Does the investigator, the investigator's spouse and dependent children collectively have, at any point since the time the investigator began participating in the Project, an equity (ownership) interest, including stock options, shares, American Depository Receipts, or other shareholder interest, exceeding US$50,000 equivalent in any entity with an interest in the outcome of the Project?
2) Does the investigator, the investigator's spouse and dependent children and any of the investigator's affiliated institutions have, since the time the investigator began participating as an investigator in the Project, collectively received non-Project related payments exceeding the cumulative value of US$25,000 from any person or entity with an interest in the outcome of the Project?
3) Any other financial relationship that could be material to a subject's decision to participate in the study.
If you need to request a grant extension or permission to carry over unspent funds, please include the request in this section. Please note that if your IRB approval has expired, any requests and/or payments will not be approved until we have received and reviewed all required documents. Please allow 2-3 months from the deadline date for a complete review/payment approval.
SMRI needs current IRB approval on file. Please send any IRB updates to Jana Bowcut at firstname.lastname@example.org or by fax at 301-571-0768. Please note that informed consent forms are no longer required.