Thomas Jefferson University s2

OHR-12A 5/2013 TJU Office of Human Research Adding/Removing JKCCN Sites & Key Personnel

IRB Control #: Department: PI:

Study Title:

Contact Person: Phone/Fax/Email:

Directions: Use the OHR-12A for adding or removing JKCCN sites & key personnel from a research study. Use one OHR-12A per site. When adding JKCCN site, include signed Addendum to IRB Authorization Agreement (IAA), site-specific consent form addendum, and OHR-1 signed by added personnel. Once approved, the OHR-12A is signed by an IRB Official and is faxed to the identified contact person.

*Also, when adding personnel, please email or fax a copy of this OHR-12A to [email protected] or 215-923-3613, in the Office of University Counsel, for COI review.

(Check appropriate sites) Added personnel: Removed personnel:

Albert Einstein Medical Center Associates in Hematology/ Oncology (AHO) Ephrata Cancer Center Frankford Hospital Hematology/Oncology Associates of NEPA Hudson Valley Oncology Associates Mercy Fitzgerald Hospital Northeast Radiation Oncology Center Pocono Medical Center Riddle Memorial Hospital Sparta Cancer Center Upper Delaware Valley Cancer Center

Signature of Principal Investigator Date Telephone/pager/e-mail

Do not fill out this section – For IRB Use The signature below indicates that this amendment has been approved by the Thomas Jefferson University IRB.

______IRB Official Date of Approval

J. Bruce Smith, M.D, CIP Kyle Conner, M.A., CIP Mary Rose Taft Patricia Oden Director, DHSP Associate Director, DHSP Executive Sec’y, IRBs Admin. Sec’y, IRB