This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^^\d\d\d\-\d\d\d\d\d\d\d\-\d\d\d\d\d\d\d\d\-\d\d$$/i

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([0-9]{3})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

qvGcrmkaVM5TuMSU5WUG4qPPFNL3vZwBSIcV3A8bvHVtwMzxYubIW7eNVmXXev8U48oxrNKFony7QfGEhNTExCQmwNV7qXNmDJ2hE

Single IRB Request_Intake Form

Returning?

A A A

Please complete this form 5 weeks before the federal funding proposal deadline to request the Northwestern University IRB Office evaluate whether it is appropriate for the Northwestern University IRB to:

Serve as the Single (main) IRB for external sites; OR
Rely on the review of an external IRB

Thank you,

Northwestern University IRB Office

Page 1 of 5

Is this the first pre-consultation request for this grant application or a re-submission?

* must provide value

Initial Submission

Re-Submission

reset

Why are you re-submitting this request?

* must provide value

Expand

Upload your previous per-consultation request.

Do not upload a previous Letter of Support or IRB Review Fee Quote.

NOTE: If you are unable to find to access your previous pre-consultation request you may request a copy by emailing IRBReliance@Northwestern.edu and sending the corresponding Letter of Support.

Upload file

Reviewing your previous pre-consultation request.

Have there been any changes since your last submission?

* must provide value

Yes

reset

Provide a detailed breakdown of the changes since your last submission.

* must provide value

Expand

Proposal Title

Note: This will be included in the Letter of Support should this project meet the requirements.

* must provide value

Expand

Northwestern Sponsored Research InfoEd ID Number

If you are requesting that Northwestern serve as the Single IRB, you will not be provided a letter of support or a quote for IRB fees without providing the InfoEd ID Number.

(InfoEd Login: https://infoed.northwestern.edu/)
(InfoEd Questions: https://osr.northwestern.edu/resources/infoed)

Funding Institute, Center, Office, Agency

* must provide value

NIH Office of the Director (OD)

National Cancer Institute (NCI)

National Eye Institute (NEI)

National Heart, Lung, and Blood Institute (NHLBI)

National Human Genome Research Institute (NHGRI)

National Institute on Aging (NIA)

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

National Institute of Allergy and Infectious Diseases (NIAID)

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

National Institute of Biomedical Imaging and Bioengineering (NIBIB)

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

National Institute on Deafness and Other Communication Disorders (NIDCD)

National Institute of Dental and Craniofacial Research (NIDCR)

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

National Institute on Drug Abuse (NIDA)

National Institute of Environmental Health Sciences (NIEHS)

National Institute of General Medical Sciences (NIGMS)

National Institute of Mental Health (NIMH)

National Institute on Minority Health and Health Disparities (NIMHD)

National Institute of Neurological Disorders and Stroke (NINDS)

National Institute of Nursing Research (NINR)

National Library of Medicine (NLM)

NIH Clinical Center (CC)

Center for Information Technology (CIT)

Center for Scientific Review (CSR)

Fogarty International Center (FIC)

National Center for Advancing Translational Sciences (NCATS)

National Center for Complementary and Integrative Health (NCCIH)

Agency for Healthcare Research and Quality (AHRQ)

Patient-Centered Outcomes Research Institute (PCORI)

National Science Foundation (NSF)

Department of Defense (DOD)

Other

Name of Other Funding Entity

* must provide value

Funding Opportunity Type

(E.g., R01, R21, U01)

Proposal Due Date set by the Funding Agency, if applicable.

NOTE: Provide the date, even if the date is in the past.

M-D-Y

By what date do you need the final response from the IRB Office?

(The IRB Office will work to the best of its ability to meet your ideal date, however this is not a guarantee.)

* must provide value

M-D-Y

What is the status of the prime funding proposal?

(Choose all that apply)

* must provide value

The Proposal has NOT been submitted to the Funder

The Proposal HAS been submitted to the Funder, and we are awaiting a response

The Funder is requesting Just In Time (JIT) information

The Proposal has been funded

The Study has been submitted in eIRB+

Northwestern University eIRB+ study number.
(E.g., STU00212345)

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.