Version 07/14/11
VALENCIA COLLEGE
Human Research Protection (HRP) Institutional Review Board (IRB)
IRB Addendum/Modification Request Form (for Internal and External Investigators)
IRB Number of Currently-Approved Research Protocol: ________________________________________
Title of Currently-Approved Research Protocol: _______________________________________________
_______________________________________________
SECTION 1
Principal Investigator (PI): ___________________________________________________________________
Address: _______________________________________________ Phone: _____________________
PI Signature: _______________________________________________ Date: ____________________
PI Supervisor/Administrator Signature: ________________________________ Date: ______________
SECTION 2
Description of Addendum/Modification Requested:
Reason for Addendum/Modification:
Notes:
Attach to this form all revised/new consent forms, altered data collection instruments, and/or any other
documents that have been updated or created.
Attach a clean printout of each document. Proposed changes on revised documents must be clearly
indicated (e.g. use of bold print, highlighting).
Addendum/Modification requests will be subject to the same standards as Initial IRB review requests
This Addendum/Modification Request Form does NOT extend the IRB approval period nor replace the
Continuing Review/Termination Form for renewal of the study.
If you have any remaining questions about Valencia’s IRB process, contact the IRB Chair at irb@valenciacollege.edu
.
THANKS!
______________ ___________________ ________________ ________________
Date Received Date Distributed to IRB Date of IRB Vote IRB Determination
by IRB Chair or (if applicable) (if applicable)
Designated Rep ________________
IRB Addendum #
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