## NOTICE OF INTENT TO RELY ON ANOTHER UC IRB 

**At UC Berkeley, LBNL, UC Davis or UC San Francisco**

+-------------------------------+--------------------------------------+
| **Instructions to the         | **Instructions to the Principal      |
| Principal Investigator/Lead   | Investigator/Lead Investigator at    |
| Investigator at the           | the *Relying* IRB**                  |
| *Reviewing* IRB**             |                                      |
+-------------------------------+--------------------------------------+
| 1.  Read the decision tree    | 1.  Read the decision tree for an    |
|     for an overview of the    |     overview of the process and      |
|     process and points to     |     points to consider when          |
|     consider when determining |     determining which IRB should     |
|     which IRB should provide  |     provide review.                  |
|     review.                   |                                      |
+-------------------------------+--------------------------------------+
| 2.  Complete this Notice and  | 2.  Ensure you provide the necessary |
|     ensure that information   |     information, for this Notice to  |
|     about the research at the |     be completed, to the PI/LI at    |
|     other UC sites is         |     the Reviewing IRB.               |
|     included.                 |                                      |
+-------------------------------+--------------------------------------+
| 3.  Obtain the signature of   | 3.  As the Relying PI/LI, sign the   |
|     the Relying PI/LI on the  |     Notice which will be transmitted |
|     Notice.                   |     to you by the Reviewing PI/LI    |
|                               |     and return it to the Reviewing   |
|                               |     PI/LI. Please note, an           |
|                               |     electronic signature is          |
|                               |     acceptable.                      |
+-------------------------------+--------------------------------------+
| 4.  Submit the completed      | 4.  Wait for notification of IRB     |
|     Notice with your IRB      |     Approval from the Reviewing      |
|     Application Forms to your |     PI/LI.                           |
|     Reviewing IRB.            |                                      |
+-------------------------------+--------------------------------------+
| 5.  Once approved, provide a  | 5.  Once you receive a complete copy |
|     complete packet of the    |     of the IRB approved study from   |
|     IRB approved study and    |     the Reviewing PI/LI, submit a    |
|     forms to the Relying      |     copy of the signed Notice to     |
|     PI/LI.                    |     your IRB (Relying IRB) who will  |
|                               |     issue you an Acknowledgment      |
|                               |     Letter.                          |
+-------------------------------+--------------------------------------+
| 6.  You can begin the study.  | 6.  You can begin the study.         |
+-------------------------------+--------------------------------------+

+-------------------------------+---+----+---+------------+-----------+
| **A. Reviewing Campus         |   |    |   |            |           |
| Principal Investigator/Lead   |   |    |   |            |           |
| Investigator:**               |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| 1.  **UC Location Which Will  |   |    |   |            |           |
|     Provide IRB               |   |    |   |            |           |
|     Review/Project Number or  |   |    |   |            |           |
|     IRB Approval Number:**    |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| \[ \] UC Berkeley / \[ \]     |   |    |   |            |           |
| Lawrence Berkeley National    |   |    |   |            |           |
| Lab /                         |   |    |   |            |           |
|                               |   |    |   |            |           |
| \[ \] UC Davis / \[ \] UC San |   |    |   |            |           |
| Francisco /                   |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| **2. Funding Information**    |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| a\. Type of Funding           |   | b  |   |            |           |
|                               |   | \. |   |            |           |
|                               |   | A  |   |            |           |
|                               |   | wa |   |            |           |
|                               |   | rd |   |            |           |
|                               |   | In |   |            |           |
|                               |   | fo |   |            |           |
|                               |   | rm |   |            |           |
|                               |   | at |   |            |           |
|                               |   | io |   |            |           |
|                               |   | n: |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| \[ \]Contract/Grant           |   | \[ |   |            |           |
|                               |   | \  |   |            |           |
| \[ \]Subcontract              |   | ]F |   |            |           |
|                               |   | ed |   |            |           |
| \[ \]Drug/device donation     |   | er |   |            |           |
|                               |   | al |   |            |           |
| \[ \]Departmental             |   | Go |   |            |           |
|                               |   | ve |   |            |           |
| \[ \]Gift                     |   | rn |   |            |           |
|                               |   | me |   |            |           |
| \[ \]Student project          |   | nt |   |            |           |
|                               |   |    |   |            |           |
| \[ \]Other: \_\_              |   | \[ |   |            |           |
|                               |   | \  |   |            |           |
| Have funds been awarded?      |   | ]O |   |            |           |
|                               |   | th |   |            |           |
| \[ \] Yes \[ \] Pending \[ \] |   | er |   |            |           |
| No                            |   | Go |   |            |           |
|                               |   | v. |   |            |           |
|                               |   | (e |   |            |           |
|                               |   | .g |   |            |           |
|                               |   | ., |   |            |           |
|                               |   | St |   |            |           |
|                               |   | at |   |            |           |
|                               |   | e, |   |            |           |
|                               |   | lo |   |            |           |
|                               |   | ca |   |            |           |
|                               |   | l) |   |            |           |
|                               |   |    |   |            |           |
|                               |   | \[ |   |            |           |
|                               |   | \] |   |            |           |
|                               |   | In |   |            |           |
|                               |   | du |   |            |           |
|                               |   | st |   |            |           |
|                               |   | ry |   |            |           |
|                               |   |    |   |            |           |
|                               |   | \[ |   |            |           |
|                               |   | \  |   |            |           |
|                               |   | ]O |   |            |           |
|                               |   | th |   |            |           |
|                               |   | er |   |            |           |
|                               |   | P  |   |            |           |
|                               |   | ri |   |            |           |
|                               |   | va |   |            |           |
|                               |   | te |   |            |           |
|                               |   |    |   |            |           |
|                               |   | \[ |   |            |           |
|                               |   | \] |   |            |           |
|                               |   | Ca |   |            |           |
|                               |   | mp |   |            |           |
|                               |   | us |   |            |           |
|                               |   | /U |   |            |           |
|                               |   | C- |   |            |           |
|                               |   | Wi |   |            |           |
|                               |   | de |   |            |           |
|                               |   | p  |   |            |           |
|                               |   | ro |   |            |           |
|                               |   | gr |   |            |           |
|                               |   | am |   |            |           |
|                               |   |    |   |            |           |
|                               |   | \[ |   |            |           |
|                               |   | \] |   |            |           |
|                               |   | De |   |            |           |
|                               |   | pa |   |            |           |
|                               |   | rt |   |            |           |
|                               |   | me |   |            |           |
|                               |   | nt |   |            |           |
|                               |   | al |   |            |           |
|                               |   | F  |   |            |           |
|                               |   | un |   |            |           |
|                               |   | ds |   |            |           |
|                               |   |    |   |            |           |
|                               |   | \[ |   |            |           |
|                               |   | \] |   |            |           |
|                               |   | Ot |   |            |           |
|                               |   | he |   |            |           |
|                               |   | r: |   |            |           |
|                               |   |    |   |            |           |
|                               |   | S  |   |            |           |
|                               |   | pe |   |            |           |
|                               |   | ci |   |            |           |
|                               |   | fy |   |            |           |
|                               |   | na |   |            |           |
|                               |   | me |   |            |           |
|                               |   | of |   |            |           |
|                               |   | sp |   |            |           |
|                               |   | on |   |            |           |
|                               |   | so |   |            |           |
|                               |   | r: |   |            |           |
|                               |   | \_ |   |            |           |
|                               |   | \_ |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| **3. Who is the Primary       |   | ** |   |            |           |
| Awardee Institution?**        |   | 4. |   |            |           |
|                               |   | W  |   |            |           |
|                               |   | ho |   |            |           |
|                               |   | is |   |            |           |
|                               |   | t  |   |            |           |
|                               |   | he |   |            |           |
|                               |   | PI |   |            |           |
|                               |   | on |   |            |           |
|                               |   | th |   |            |           |
|                               |   | is |   |            |           |
|                               |   | aw |   |            |           |
|                               |   | ar |   |            |           |
|                               |   | d? |   |            |           |
|                               |   | ** |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
|                               |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| **5. PI/LI on the IRB         |   |    |   |            |           |
| Application:**                |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Name and degree               | U |    |   | Department |           |
|                               | n |    |   |            |           |
|                               | i |    |   |            |           |
|                               | v |    |   |            |           |
|                               | e |    |   |            |           |
|                               | r |    |   |            |           |
|                               | s |    |   |            |           |
|                               | i |    |   |            |           |
|                               | t |    |   |            |           |
|                               | y |    |   |            |           |
|                               | T |    |   |            |           |
|                               | i |    |   |            |           |
|                               | t |    |   |            |           |
|                               | l |    |   |            |           |
|                               | e |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Mailing Address               | P |    |   | E-mail     |           |
|                               | h |    |   | Address    |           |
|                               | o |    |   |            |           |
|                               | n |    |   |            |           |
|                               | e |    |   |            |           |
|                               | N |    |   |            |           |
|                               | u |    |   |            |           |
|                               | m |    |   |            |           |
|                               | b |    |   |            |           |
|                               | e |    |   |            |           |
|                               | r |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Contact Person:               |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Name and degree               | U |    |   | Department |           |
|                               | n |    |   |            |           |
|                               | i |    |   |            |           |
|                               | v |    |   |            |           |
|                               | e |    |   |            |           |
|                               | r |    |   |            |           |
|                               | s |    |   |            |           |
|                               | i |    |   |            |           |
|                               | t |    |   |            |           |
|                               | y |    |   |            |           |
|                               | T |    |   |            |           |
|                               | i |    |   |            |           |
|                               | t |    |   |            |           |
|                               | l |    |   |            |           |
|                               | e |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Mailing Address               | P |    |   | E-mail     |           |
|                               | h |    |   | Address    |           |
|                               | o |    |   |            |           |
|                               | n |    |   |            |           |
|                               | e |    |   |            |           |
|                               | N |    |   |            |           |
|                               | u |    |   |            |           |
|                               | m |    |   |            |           |
|                               | b |    |   |            |           |
|                               | e |    |   |            |           |
|                               | r |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Additional Contact Person (if |   |    |   |            |           |
| any):                         |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Name                          | U |    |   | Department |           |
|                               | n |    |   |            |           |
|                               | i |    |   |            |           |
|                               | v |    |   |            |           |
|                               | e |    |   |            |           |
|                               | r |    |   |            |           |
|                               | s |    |   |            |           |
|                               | i |    |   |            |           |
|                               | t |    |   |            |           |
|                               | y |    |   |            |           |
|                               | T |    |   |            |           |
|                               | i |    |   |            |           |
|                               | t |    |   |            |           |
|                               | l |    |   |            |           |
|                               | e |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| Campus Mailing Address (Box   | P |    |   | E-mail     |           |
| No.)                          | h |    |   | Address    |           |
|                               | o |    |   |            |           |
|                               | n |    |   |            |           |
|                               | e |    |   |            |           |
|                               | N |    |   |            |           |
|                               | u |    |   |            |           |
|                               | m |    |   |            |           |
|                               | b |    |   |            |           |
|                               | e |    |   |            |           |
|                               | r |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+
| **6. Study Title:**           |   |    | * |            | **8.      |
|                               |   |    | * |            | Review    |
|                               |   |    | 7 |            | Type**    |
|                               |   |    | . |            |           |
|                               |   |    | A |            |           |
|                               |   |    | p |            |           |
|                               |   |    | p |            |           |
|                               |   |    | l |            |           |
|                               |   |    | i |            |           |
|                               |   |    | c |            |           |
|                               |   |    | a |            |           |
|                               |   |    | t |            |           |
|                               |   |    | i |            |           |
|                               |   |    | o |            |           |
|                               |   |    | n |            |           |
|                               |   |    | T |            |           |
|                               |   |    | y |            |           |
|                               |   |    | p |            |           |
|                               |   |    | e |            |           |
|                               |   |    | * |            |           |
|                               |   |    | * |            |           |
+-------------------------------+---+----+---+------------+-----------+
|                               |   |    | \ |            | \[ \]     |
|                               |   |    | [ |            | Full      |
|                               |   |    | \ |            | Committee |
|                               |   |    | ] |            |           |
|                               |   |    | N |            | \[ \]     |
|                               |   |    | e |            | Expedited |
|                               |   |    | w |            | Review    |
|                               |   |    |   |            |           |
|                               |   |    | \ |            | \[ \]     |
|                               |   |    | [ |            | Exempt    |
|                               |   |    | \ |            |           |
|                               |   |    | ] |            |           |
|                               |   |    | M |            |           |
|                               |   |    | o |            |           |
|                               |   |    | d |            |           |
|                               |   |    | i |            |           |
|                               |   |    | f |            |           |
|                               |   |    | i |            |           |
|                               |   |    | c |            |           |
|                               |   |    | a |            |           |
|                               |   |    | t |            |           |
|                               |   |    | i |            |           |
|                               |   |    | o |            |           |
|                               |   |    | n |            |           |
|                               |   |    |   |            |           |
|                               |   |    | \ |            |           |
|                               |   |    | [ |            |           |
|                               |   |    | \ |            |           |
|                               |   |    | ] |            |           |
|                               |   |    | R |            |           |
|                               |   |    | e |            |           |
|                               |   |    | n |            |           |
|                               |   |    | e |            |           |
|                               |   |    | w |            |           |
|                               |   |    | a |            |           |
|                               |   |    | l |            |           |
|                               |   |    | ( |            |           |
|                               |   |    | C |            |           |
|                               |   |    | o |            |           |
|                               |   |    | n |            |           |
|                               |   |    | t |            |           |
|                               |   |    | i |            |           |
|                               |   |    | n |            |           |
|                               |   |    | u |            |           |
|                               |   |    | i |            |           |
|                               |   |    | n |            |           |
|                               |   |    | g |            |           |
|                               |   |    | R |            |           |
|                               |   |    | e |            |           |
|                               |   |    | v |            |           |
|                               |   |    | i |            |           |
|                               |   |    | e |            |           |
|                               |   |    | w |            |           |
|                               |   |    | ) |            |           |
+-------------------------------+---+----+---+------------+-----------+
| 9.  **Provide a brief         |   |    |   |            |           |
|     synopsis or abstract of   |   |    |   |            |           |
|     the entire study: Space   |   |    |   |            |           |
|     limit: half page**        |   |    |   |            |           |
|                               |   |    |   |            |           |
| Please provide a general      |   |    |   |            |           |
| description of the overall    |   |    |   |            |           |
| study. The synopsis should be |   |    |   |            |           |
| nor more than half a page.    |   |    |   |            |           |
+-------------------------------+---+----+---+------------+-----------+

+-------------------------------+---+---+--------+-------------------------+
| **B. Relying Campus Principal |   |   |        |                         |
| Investigator/Lead             |   |   |        |                         |
| Investigator: Note: Copy this |   |   |        |                         |
| section (B) to include        |   |   |        |                         |
| information for each relying  |   |   |        |                         |
| campus.**                     |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| 1.  **UC Location Which Will  |   |   |        |                         |
|     Rely on the Reviewing IRB |   |   |        |                         |
|     Review/Project Number or  |   |   |        |                         |
|     IRB Approval Number:**    |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| \[ \] UC Berkeley / \[ \]     |   |   |        |                         |
| Lawrence Berkeley National    |   |   |        |                         |
| Lab /                         |   |   |        |                         |
|                               |   |   |        |                         |
| \[ \] UC Davis / \[ \] UC San |   |   |        |                         |
| Francisco /                   |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| **2. Funding Information**    |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| a\. Type of Funding           |   | b |        |                         |
|                               |   | \ |        |                         |
|                               |   | . |        |                         |
|                               |   | A |        |                         |
|                               |   | w |        |                         |
|                               |   | a |        |                         |
|                               |   | r |        |                         |
|                               |   | d |        |                         |
|                               |   | I |        |                         |
|                               |   | n |        |                         |
|                               |   | f |        |                         |
|                               |   | o |        |                         |
|                               |   | r |        |                         |
|                               |   | m |        |                         |
|                               |   | a |        |                         |
|                               |   | t |        |                         |
|                               |   | i |        |                         |
|                               |   | o |        |                         |
|                               |   | n |        |                         |
|                               |   | : |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| \[ \]Contract/Grant           |   | \ |        |                         |
|                               |   | [ |        |                         |
| \[ \]Subcontract              |   | \ |        |                         |
|                               |   | ] |        |                         |
| \[ \]Drug/device donation     |   | F |        |                         |
|                               |   | e |        |                         |
| \[ \]Departmental             |   | d |        |                         |
|                               |   | e |        |                         |
| \[ \]Gift                     |   | r |        |                         |
|                               |   | a |        |                         |
| \[ \]Student project          |   | l |        |                         |
|                               |   | G |        |                         |
| \[ \]Other: \_\_              |   | o |        |                         |
|                               |   | v |        |                         |
| Have funds been awarded?      |   | e |        |                         |
|                               |   | r |        |                         |
| \[ \] Yes \[ \] Pending \[ \] |   | n |        |                         |
| No                            |   | m |        |                         |
|                               |   | e |        |                         |
|                               |   | n |        |                         |
|                               |   | t |        |                         |
|                               |   |   |        |                         |
|                               |   | \ |        |                         |
|                               |   | [ |        |                         |
|                               |   | \ |        |                         |
|                               |   | ] |        |                         |
|                               |   | O |        |                         |
|                               |   | t |        |                         |
|                               |   | h |        |                         |
|                               |   | e |        |                         |
|                               |   | r |        |                         |
|                               |   | G |        |                         |
|                               |   | o |        |                         |
|                               |   | v |        |                         |
|                               |   | . |        |                         |
|                               |   | ( |        |                         |
|                               |   | e |        |                         |
|                               |   | . |        |                         |
|                               |   | g |        |                         |
|                               |   | . |        |                         |
|                               |   | , |        |                         |
|                               |   | S |        |                         |
|                               |   | t |        |                         |
|                               |   | a |        |                         |
|                               |   | t |        |                         |
|                               |   | e |        |                         |
|                               |   | , |        |                         |
|                               |   | l |        |                         |
|                               |   | o |        |                         |
|                               |   | c |        |                         |
|                               |   | a |        |                         |
|                               |   | l |        |                         |
|                               |   | ) |        |                         |
|                               |   |   |        |                         |
|                               |   | \ |        |                         |
|                               |   | [ |        |                         |
|                               |   | \ |        |                         |
|                               |   | ] |        |                         |
|                               |   | I |        |                         |
|                               |   | n |        |                         |
|                               |   | d |        |                         |
|                               |   | u |        |                         |
|                               |   | s |        |                         |
|                               |   | t |        |                         |
|                               |   | r |        |                         |
|                               |   | y |        |                         |
|                               |   |   |        |                         |
|                               |   | \ |        |                         |
|                               |   | [ |        |                         |
|                               |   | \ |        |                         |
|                               |   | ] |        |                         |
|                               |   | O |        |                         |
|                               |   | t |        |                         |
|                               |   | h |        |                         |
|                               |   | e |        |                         |
|                               |   | r |        |                         |
|                               |   | P |        |                         |
|                               |   | r |        |                         |
|                               |   | i |        |                         |
|                               |   | v |        |                         |
|                               |   | a |        |                         |
|                               |   | t |        |                         |
|                               |   | e |        |                         |
|                               |   |   |        |                         |
|                               |   | \ |        |                         |
|                               |   | [ |        |                         |
|                               |   | \ |        |                         |
|                               |   | ] |        |                         |
|                               |   | C |        |                         |
|                               |   | a |        |                         |
|                               |   | m |        |                         |
|                               |   | p |        |                         |
|                               |   | u |        |                         |
|                               |   | s |        |                         |
|                               |   | / |        |                         |
|                               |   | U |        |                         |
|                               |   | C |        |                         |
|                               |   | - |        |                         |
|                               |   | W |        |                         |
|                               |   | i |        |                         |
|                               |   | d |        |                         |
|                               |   | e |        |                         |
|                               |   | p |        |                         |
|                               |   | r |        |                         |
|                               |   | o |        |                         |
|                               |   | g |        |                         |
|                               |   | r |        |                         |
|                               |   | a |        |                         |
|                               |   | m |        |                         |
|                               |   |   |        |                         |
|                               |   | \ |        |                         |
|                               |   | [ |        |                         |
|                               |   | \ |        |                         |
|                               |   | ] |        |                         |
|                               |   | D |        |                         |
|                               |   | e |        |                         |
|                               |   | p |        |                         |
|                               |   | a |        |                         |
|                               |   | r |        |                         |
|                               |   | t |        |                         |
|                               |   | m |        |                         |
|                               |   | e |        |                         |
|                               |   | n |        |                         |
|                               |   | t |        |                         |
|                               |   | a |        |                         |
|                               |   | l |        |                         |
|                               |   | F |        |                         |
|                               |   | u |        |                         |
|                               |   | n |        |                         |
|                               |   | d |        |                         |
|                               |   | s |        |                         |
|                               |   |   |        |                         |
|                               |   | \ |        |                         |
|                               |   | [ |        |                         |
|                               |   | \ |        |                         |
|                               |   | ] |        |                         |
|                               |   | O |        |                         |
|                               |   | t |        |                         |
|                               |   | h |        |                         |
|                               |   | e |        |                         |
|                               |   | r |        |                         |
|                               |   | : |        |                         |
|                               |   |   |        |                         |
|                               |   | S |        |                         |
|                               |   | p |        |                         |
|                               |   | e |        |                         |
|                               |   | c |        |                         |
|                               |   | i |        |                         |
|                               |   | f |        |                         |
|                               |   | y |        |                         |
|                               |   | n |        |                         |
|                               |   | a |        |                         |
|                               |   | m |        |                         |
|                               |   | e |        |                         |
|                               |   | o |        |                         |
|                               |   | f |        |                         |
|                               |   | s |        |                         |
|                               |   | p |        |                         |
|                               |   | o |        |                         |
|                               |   | n |        |                         |
|                               |   | s |        |                         |
|                               |   | o |        |                         |
|                               |   | r |        |                         |
|                               |   | : |        |                         |
|                               |   | \ |        |                         |
|                               |   | _ |        |                         |
|                               |   | \ |        |                         |
|                               |   | _ |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| **3. PI/LI at the relying     |   |   |        |                         |
| campus:**                     |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Name and degree               | U |   |        | Department              |
|                               | n |   |        |                         |
|                               | i |   |        |                         |
|                               | v |   |        |                         |
|                               | e |   |        |                         |
|                               | r |   |        |                         |
|                               | s |   |        |                         |
|                               | i |   |        |                         |
|                               | t |   |        |                         |
|                               | y |   |        |                         |
|                               | T |   |        |                         |
|                               | i |   |        |                         |
|                               | t |   |        |                         |
|                               | l |   |        |                         |
|                               | e |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Mailing Address               | P |   |        | E-mail Address          |
|                               | h |   |        |                         |
|                               | o |   |        |                         |
|                               | n |   |        |                         |
|                               | e |   |        |                         |
|                               | N |   |        |                         |
|                               | u |   |        |                         |
|                               | m |   |        |                         |
|                               | b |   |        |                         |
|                               | e |   |        |                         |
|                               | r |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Contact Person:               |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Name and degree               | U |   |        | Department              |
|                               | n |   |        |                         |
|                               | i |   |        |                         |
|                               | v |   |        |                         |
|                               | e |   |        |                         |
|                               | r |   |        |                         |
|                               | s |   |        |                         |
|                               | i |   |        |                         |
|                               | t |   |        |                         |
|                               | y |   |        |                         |
|                               | T |   |        |                         |
|                               | i |   |        |                         |
|                               | t |   |        |                         |
|                               | l |   |        |                         |
|                               | e |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Mailing Address               | P |   |        | E-mail Address          |
|                               | h |   |        |                         |
|                               | o |   |        |                         |
|                               | n |   |        |                         |
|                               | e |   |        |                         |
|                               | N |   |        |                         |
|                               | u |   |        |                         |
|                               | m |   |        |                         |
|                               | b |   |        |                         |
|                               | e |   |        |                         |
|                               | r |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Additional Contact Person (if |   |   |        |                         |
| any):                         |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Name                          | U |   |        | Department              |
|                               | n |   |        |                         |
|                               | i |   |        |                         |
|                               | v |   |        |                         |
|                               | e |   |        |                         |
|                               | r |   |        |                         |
|                               | s |   |        |                         |
|                               | i |   |        |                         |
|                               | t |   |        |                         |
|                               | y |   |        |                         |
|                               | T |   |        |                         |
|                               | i |   |        |                         |
|                               | t |   |        |                         |
|                               | l |   |        |                         |
|                               | e |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| Campus Mailing Address (Box   | P |   |        | E-mail Address          |
| No.)                          | h |   |        |                         |
|                               | o |   |        |                         |
|                               | n |   |        |                         |
|                               | e |   |        |                         |
|                               | N |   |        |                         |
|                               | u |   |        |                         |
|                               | m |   |        |                         |
|                               | b |   |        |                         |
|                               | e |   |        |                         |
|                               | r |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| **4. Provide a summary of the |   |   |        |                         |
| Relying PIs/LIs scope of work |   |   |        |                         |
| and activities. For example,  |   |   |        |                         |
| please include any of the     |   |   |        |                         |
| study procedures,             |   |   |        |                         |
| interventions, diagnostics,   |   |   |        |                         |
| or analysis that will take    |   |   |        |                         |
| place.**                      |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
|                               |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
| 6.  **Will the Relying PI/LI  |   |   | \[ \]  |                         |
|     recruit and consent       |   |   | Yes \[ |                         |
|     subjects**                |   |   | \] No  |                         |
+-------------------------------+---+---+--------+-------------------------+
| If yes, please provide a      |   |   |        |                         |
| brief discussion of the       |   |   |        |                         |
| following:                    |   |   |        |                         |
|                               |   |   |        |                         |
| a.  Types and numbers of      |   |   |        |                         |
|     subjects, and             |   |   |        |                         |
|                               |   |   |        |                         |
| b.  How, when, where, and by  |   |   |        |                         |
|     whom are potential        |   |   |        |                         |
|     subjects approached?      |   |   |        |                         |
|                               |   |   |        |                         |
| c.  Provide a brief           |   |   |        |                         |
|     description of how        |   |   |        |                         |
|     informed consent          |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+
|                               |   |   |        |                         |
+-------------------------------+---+---+--------+-------------------------+

+-----------------+----------------+---+------------------+--------------+
| **C. Other      |                |   | \[ \] Yes \[ \]  |              |
| Appr            |                |   | No               |              |
| ovals/Regulated |                |   |                  |              |
| Materials:**    |                |   | If "Yes",        |              |
| Does this study |                |   | complete the     |              |
| require         |                |   | applicable       |              |
| approval or     |                |   | section(s) below |              |
| authorization   |                |   | and identify     |              |
| from any of the |                |   | which UC School  |              |
| following       |                |   | will or has      |              |
| oversight or    |                |   | provided the     |              |
| regulatory      |                |   | review.          |              |
| committees, or  |                |   |                  |              |
| involve the use |                |   | Acknowledgment   |              |
| of regulated    |                |   | Letters will not |              |
| materials       |                |   | be provided from |              |
| listed below?   |                |   | the Relying IRB  |              |
|                 |                |   | if the below     |              |
|                 |                |   | approvals are    |              |
|                 |                |   | not in place.    |              |
+-----------------+----------------+---+------------------+--------------+
| Cancer Center   | Date of        | \ |                  |              |
| Protocol Review | review:        | [ |                  |              |
| Committee       |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | U |                  |              |
|                 |                | C |                  |              |
|                 |                | D |                  |              |
|                 |                | a |                  |              |
|                 |                | v |                  |              |
|                 |                | i |                  |              |
|                 |                | s |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | U |                  |              |
|                 |                | C |                  |              |
|                 |                | S |                  |              |
|                 |                | a |                  |              |
|                 |                | n |                  |              |
|                 |                | F |                  |              |
|                 |                | r |                  |              |
|                 |                | a |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | i |                  |              |
|                 |                | s |                  |              |
|                 |                | c |                  |              |
|                 |                | o |                  |              |
+-----------------+----------------+---+------------------+--------------+
| Institutional   | BUA# for each  | \ |                  | \[ \] UC     |
| Biosafety       | site:          | [ |                  | Davis        |
| Committee       |                | \ |                  |              |
|                 |                | ] |                  | \[ \] UC San |
|                 |                | U |                  | Francisco    |
|                 |                | C |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | w |                  |              |
|                 |                | r |                  |              |
|                 |                | e |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | e |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                | N |                  |              |
|                 |                | a |                  |              |
|                 |                | t |                  |              |
|                 |                | i |                  |              |
|                 |                | o |                  |              |
|                 |                | n |                  |              |
|                 |                | a |                  |              |
|                 |                | l |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | b |                  |              |
+-----------------+----------------+---+------------------+--------------+
| Human Stem      | Oversight      | \ |                  | \[ \] UC     |
| Cells           | Review         | [ |                  | Davis        |
|                 | Committee      | \ |                  |              |
|                 | Approval:      | ] |                  | \[ \] UC San |
|                 |                | U |                  | Francisco    |
|                 |                | C |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | w |                  |              |
|                 |                | r |                  |              |
|                 |                | e |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | e |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                | N |                  |              |
|                 |                | a |                  |              |
|                 |                | t |                  |              |
|                 |                | i |                  |              |
|                 |                | o |                  |              |
|                 |                | n |                  |              |
|                 |                | a |                  |              |
|                 |                | l |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | b |                  |              |
+-----------------+----------------+---+------------------+--------------+
| Radiation       | RUA#:          | \ |                  | \[ \] UC     |
| Safety          |                | [ |                  | Davis        |
| Committee       |                | \ |                  |              |
|                 |                | ] |                  | \[ \] UC San |
|                 |                | U |                  | Francisco    |
|                 |                | C |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | w |                  |              |
|                 |                | r |                  |              |
|                 |                | e |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | e |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                | N |                  |              |
|                 |                | a |                  |              |
|                 |                | t |                  |              |
|                 |                | i |                  |              |
|                 |                | o |                  |              |
|                 |                | n |                  |              |
|                 |                | a |                  |              |
|                 |                | l |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | b |                  |              |
+-----------------+----------------+---+------------------+--------------+
| Radioactive     | Approval date: | \ |                  | \[ \] UC     |
| Drug Research   |                | [ |                  | Davis        |
| Committee       |                | \ |                  |              |
| (RDRC)          |                | ] |                  | \[ \] UC San |
|                 |                | U |                  | Francisco    |
|                 |                | C |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | w |                  |              |
|                 |                | r |                  |              |
|                 |                | e |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | e |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                | N |                  |              |
|                 |                | a |                  |              |
|                 |                | t |                  |              |
|                 |                | i |                  |              |
|                 |                | o |                  |              |
|                 |                | n |                  |              |
|                 |                | a |                  |              |
|                 |                | l |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | b |                  |              |
+-----------------+----------------+---+------------------+--------------+
| List any        | Name and IND#: | \ |                  | \[ \] UC     |
| Investigational |                | [ |                  | Davis        |
| Drugs and       |                | \ |                  |              |
| Biologics       |                | ] |                  | \[ \] UC San |
|                 |                | U |                  | Francisco    |
|                 |                | C |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | w |                  |              |
|                 |                | r |                  |              |
|                 |                | e |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | e |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                | N |                  |              |
|                 |                | a |                  |              |
|                 |                | t |                  |              |
|                 |                | i |                  |              |
|                 |                | o |                  |              |
|                 |                | n |                  |              |
|                 |                | a |                  |              |
|                 |                | l |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | b |                  |              |
+-----------------+----------------+---+------------------+--------------+
| List any        | Name and IDE#  | \ |                  | \[ \] UC     |
| Investigational | or NSR         | [ |                  | Davis        |
| Devices and     | Determination: | \ |                  |              |
| Non-Significant |                | ] |                  | \[ \] UC San |
| Risk Devices    |                | U |                  | Francisco    |
|                 |                | C |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                |   |                  |              |
|                 |                | \ |                  |              |
|                 |                | [ |                  |              |
|                 |                | \ |                  |              |
|                 |                | ] |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | w |                  |              |
|                 |                | r |                  |              |
|                 |                | e |                  |              |
|                 |                | n |                  |              |
|                 |                | c |                  |              |
|                 |                | e |                  |              |
|                 |                | B |                  |              |
|                 |                | e |                  |              |
|                 |                | r |                  |              |
|                 |                | k |                  |              |
|                 |                | e |                  |              |
|                 |                | l |                  |              |
|                 |                | e |                  |              |
|                 |                | y |                  |              |
|                 |                | N |                  |              |
|                 |                | a |                  |              |
|                 |                | t |                  |              |
|                 |                | i |                  |              |
|                 |                | o |                  |              |
|                 |                | n |                  |              |
|                 |                | a |                  |              |
|                 |                | l |                  |              |
|                 |                | L |                  |              |
|                 |                | a |                  |              |
|                 |                | b |                  |              |
+-----------------+----------------+---+------------------+--------------+

+-----------------------------------------------------------------------+
| **D. Relying Campus Principal or Lead Investigator's Assurance to the |
| Reviewing IRB:**                                                      |
+-----------------------------------------------------------------------+
| -   I certify that the information provided in this application is    |
|     complete and correct.                                             |
|                                                                       |
| -   I certify that I will follow the IRB-approved Protocol.           |
|                                                                       |
| -   I will comply with all applicable federal and state laws          |
|     regarding the protection of human subjects in research.           |
|                                                                       |
| -   I will make sure that the personnel performing this study are     |
|     qualified and adhere to the provisions of this IRB-approved       |
|     protocol.                                                         |
|                                                                       |
| -   I will not modify this protocol or any attached materials without |
|     first submitting an amendment to the previously approved protocol |
|     and receiving subsequent IRB approval from the Reviewing IRB.     |
|                                                                       |
| -   I accept responsibility for the conduct of this study at this     |
|     site, the ethical performance of the project, and the protection  |
|     of the rights and welfare of the human subjects who are directly  |
|     involved at this site.                                            |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_        |
|                                                                       |
| Relying Principal or Lead Investigator's Signature Date               |
|                                                                       |
| *(If more than one UC site)*                                          |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_        |
|                                                                       |
| Relying Principal or Lead Investigator's Signature Date               |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_        |
|                                                                       |
| Relying Principal or Lead Investigator's Signature Date               |
+-----------------------------------------------------------------------+

+-----------------------------------+-----------------------------------+
| > **UC Berkeley**                 | > **UC San Francisco\             |
| >                                 | > **Committee on Human Research   |
| > Office for the Protection of    | >                                 |
| > Human Subjects                  | > University of California, San   |
| >                                 | > Francisco                       |
| > University of California,       | >                                 |
| > Berkeley                        | > Office of Research              |
| >                                 | > Administration                  |
| > 2150 Shattuck Ave., Suite 313   | >                                 |
| >                                 | > Box 0962, LHts 315              |
| > Berkeley, CA  94704-5940        | >                                 |
| >                                 | > San Francisco, CA 94143         |
| > 510-642-7461                    | >                                 |
| >                                 | > 415-476-1814                    |
| > <OPHS@berkeley.edu>             | >                                 |
| >                                 | > <chr@ucsf.edu>                  |
| > [http://cphs.berkele            | >                                 |
| y.edu](http://cphs.berkeley.edu/) | > <h                              |
|                                   | ttp://www.research.ucsf.edu/chr/> |
+-----------------------------------+-----------------------------------+
| > **UC Davis**                    | > **Lawrence Berkeley National    |
| >                                 | > Lab**                           |
| > Institutional Review Board      | >                                 |
| > Administration                  | > Human and Animal Regulatory     |
| >                                 | > Committees, Berkeley Lab\       |
| > University of California, Davis | > 1 Cyclotron Road, MS 26R0143\   |
| >                                 | > Berkeley, CA 94720              |
| > CTSC Building                   | >                                 |
| >                                 | > 510-486-5507                    |
| > 2921 Stockton Blvd.             | >                                 |
| >                                 | > <CEByrne@lbl.gov>               |
| > Suite 1400, Room 1429           | >                                 |
| >                                 | > <http://www.lbl.gov/eh          |
| > Sacramento, CA 95817            | s/health_services/harc/hsc.shtml> |
| >                                 |                                   |
| > 916-703-9151                    |                                   |
| >                                 |                                   |
| > <                               |                                   |
| elodia.tarango@ucdmc.ucdavis.edu> |                                   |
| >                                 |                                   |
| > <http://w                       |                                   |
| ww.research.ucdavis.edu/irbadmin> |                                   |
+-----------------------------------+-----------------------------------+