SUNY UPSTATE MEDICAL UNIVERSITY INSTITUTIONAL REVIEW BOARDRequest for Acknowledgement of Receipt

IRB #:     

Date of Request:      

Principal Investigator:      

Study Coordinator/Contact Person: name:       number:      

Study Title:      

Study Status: open to enrollment closed to enrollment

1. Check all items submitted:

Data Monitoring Committee Report (DMC, DSMB) Date of report      

Investigator’s Brochure (IB), must Include Summary of Changes Date of IB      

NCI Central IRB (study related documents):      

Other (specify):      

2. Do any of the items listed above necessitate a Change to the Consent Document(s)?

Yes (note: submit with an amendment request form). If yes, has revised consent been submitted to the IRB for review?      

No

3. Are any subjects currently on study protocol? Yes No

4. Will additional information be provided to subjects? Yes, include how the information will be communicated to the subjects      

No,

5. Provide additional information, as needed      

*********************************************************************************************************** IRB Office Use Only: Stamp below indicates that the above noted materials have been received by the SUNY Upstate Medical University IRB Office.

Form Version Date: 8/28/2009 1 of 1