Wichita State University Institutional Review Board (IRB)
RTT February 2018
Application for Amendment
A study must be carried out in accordance with the application approved by the IRB. Any changes to the study, including
but not limited to changes in the subject population, recruitment plans, advertising materials, research procedures, survey
instruments, consent forms, sites or research personnel who are instrumental to the design or execution of the study must
be approved by the IRB prior to the change taking place.
IRB Number:
Title:
Name of Principal Investigator(s):
E-Mail Address: Campus Box: Phone:
Department/Program Affiliation:
Name(s) current of Co-Investigator(s):
Have all listed study personnel completed CITI Human Subjects Training? Yes No
Please select ALL categories of amendment(s) in which you are requesting.
Changes in currently approved application
Changes in currently approved consent form or procedures please attach revised documents and highlight
changes or use tracked changes
Changes to or Addition of survey(s), questionnaire(s), or other research instruments please attach the
revised or new instruments and highlight changes or use tracked changes
Change in Study Title
Change in Principal Investigator have both current and newly proposed PI sign this document
Addition/deletion of research personnel for new personnel list their role on the project on page 2
Change to research study design, methods or procedures (e.g., observations, interventions, collection of
biological samples or biometrics information, participant tasks, etc.)
Addition/deletion of a site
Addition of/change to study population
Addition of/change to recruitment or compensation procedure(s)
Addition of change to the identifiers collected in the study, or any others that would impact the privacy and
confidentiality of the study participants
Other changes (explain on page 2)
RTT February 2018
Briefly describe the changes being made (provide a clear rationale for the proposed changes).
Are any of these changes the result of something that occurred during human participant interaction or an
unexpected event? Yes No
Check all that apply:
This change does not increase risks to participants enrolled in the study
This change may increase risks to participants enrolled in the study
This change does necessitate revision of the consent form
This change does not necessitate revision of the consent form
Subjects already enrolled will be re-consented
By signing this form, I certify that I have disclosed to the IRB all information related to the proposed changes to
the application, accurately and completely.
PI Signature: Date:
For PI changes
New PI Signature: Date:
click to sign
signature
click to edit
click to sign
signature
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