Northwestern Health Sciences University Institutional Review Board
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Northwestern Health Sciences University Institutional Review Board Additional Co-investigators Co-investigators, responsible for knowing and following the protocol, should be listed below. Include any individual who will have responsibility for the consent process, direct data collection from subjects, or follow-up.
Name (Last name, First name MI): Highest Earned Degree:
Mailing Address: Phone Number:
University Department (if applicable): Email:
Occupational Position: Faculty Staff Student Other: Indicate the training and education completed in the protection of human subjects or human subjects records. Training is required for all research. Human Subjects Training (one of these must be checked) HIPAA Training (Required if Data Contains PHI) CITI Other (attach documentation): HIPAA
Co-investigator Name Co-investigator Title Date
Name (Last name, First name MI): Highest Earned Degree:
Mailing Address: Phone Number:
University Department (if applicable): Email:
Occupational Position: Faculty Staff Student Other: Indicate the training and education completed in the protection of human subjects or human subjects records. Training is required for all research. Human Subjects Training (one of these must be checked) HIPAA Training (Required if Data Contains PHI) CITI Other (attach documentation): HIPAA
Co-investigator Name Co-investigator Title Date
Name (Last name, First name MI): Highest Earned Degree:
Mailing Address: Phone Number:
University Department (if applicable): Email:
Occupational Position: Faculty Staff Student Other: Indicate the training and education completed in the protection of human subjects or human subjects records. Training is required for all research. Human Subjects Training (one of these must be checked) HIPAA Training (Required if Data Contains PHI) CITI Other (attach documentation): HIPAA
Co-investigator Name Co-investigator Title Date
Additional Co-investigators 1 of 2 Northwestern Health Sciences University Institutional Review Board Name (Last name, First name MI): Highest Earned Degree:
Mailing Address: Phone Number:
University Department (if applicable): Email:
Occupational Position: Faculty Staff Student Other: Indicate the training and education completed in the protection of human subjects or human subjects records. Training is required for all research. Human Subjects Training (one of these must be checked) HIPAA Training (Required if Data Contains PHI) CITI Other (attach documentation): HIPAA
Co-investigator Name Co-investigator Title Date
Name (Last name, First name MI): Highest Earned Degree:
Mailing Address: Phone Number:
University Department (if applicable): Email:
Occupational Position: Faculty Staff Student Other: Indicate the training and education completed in the protection of human subjects or human subjects records. Training is required for all research. Human Subjects Training (one of these must be checked) HIPAA Training (Required if Data Contains PHIU CITI Other (attach documentation): HIPAA
Co-investigator Name Co-investigator Title Date
Name (Last name, First name MI): Highest Earned Degree:
Mailing Address: Phone Number:
University Department (if applicable): Email:
Occupational Position: Faculty Staff Student Other: Indicate the training and education completed in the protection of human subjects or human subjects records. Training is required for all research. Human Subjects Training (one of these must be checked) HIPAA Training (Required if Data Contains PHI) CITI Other (attach documentation): HIPAA
Co-investigator Name Co-investigator Title Date
Additional Co-investigators 2 of 2