State University of New York at Potsdam Institutional Review Board

STATE UNIVERSITY OF NEW YORK AT POTSDAM INSTITUTIONAL REVIEW BOARD Appendix B – Co-Investigator(s), Student Researcher(s) or Staff Member(s) Information Sheet

Project #

 For EACH additional co-investigator or staff member involved in the study who will have contact with subjects or raw data you must submit this sheet.  For EACH additional student you must submit this form – Unless the student(s) are part of a classroom project. Then each student must complete appendix F.

Job Title:

Role (select one): Co-Investigator Student Investigator Research Staff Member

Department: Phone #: Email:

Address:

CITI course completed Date of completion: (Refresher course is required every 3 years)

I have read Appendix D Conflict of Interest guidelines and the SUNY Potsdam Conflict of Interest Policy and declare that I do not have a potential conflict of interest associated with this project.

I have read Article 24-A as amended to the New York State Public Health Law (available on the SUNY Potsdam IRB website) and agree to comply with SUNY Potsdam policy and state and federal regulations regarding the use of human subjects in research. I further agree to execute this project as described in this proposal; request approval from the IRB for changes; submit applications for continuation of approval as required and submit a final report at the conclusion of the study.

______Signature of Co-Investigator or Student Investigator Date

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I have read Appendix D Conflict of Interest guidelines and the SUNY Potsdam Conflict of Interest Policy and declare that I do not have a potential conflict of interest associated with this project.

I have read Article 24-A as amended to the New York State Public Health Law (available on the SUNY Potsdam IRB website) and agree to comply with SUNY Potsdam policy and state and federal regulations regarding the use of human subjects in research.

______Signature of Staff Member Date

Lydia Rodriguez, Chair Satterlee Hall 238 267-2688 [email protected] Rev 1.4.18