IRB APPROVAL NUMBER:___________ AMENDMENT NUMBER__________
(For IRB Use Only)
1 Revised 07/2012
VIRGINIA STATE UNIVERSITY
INSTITUTIONAL REVIEW BOARD
STUDY AMENDMENT FORM
This form must be typed and submitted Virginia State University, Office of Sponsored Research and Programs,
P. O. Box 9407, Petersburg, VA 23806.
Section I: Investigator Information
Section II: Amendment Description
1. Provide a complete description of the proposed change(s) included in this amendment:
2. Is the study sponsored/funded? Please mark (X) the appropriate line below.
YES, Check the appropriate line below and provide with this amendment, as applicable:
a copy of the sponsor’s amendment, if the amendment came from the sponsor
a copy of your notice to the sponsor of this change, if you initiated the amendment
a copy of the approved amendment will be sent to the sponsor.
3. Do the proposed change(s) described in this amendment alter the risk to benefit assessment?
YES, Please describe how the assessment is altered:
4. Do the proposed change(s) described in this amendment affect any of the following documents?
thesis, or dissertation
NOTE: Any document selected above must be included with the submission of the amendment.