Study Personnel Form

Non-Harvard Study Personnel Form Instructions: Submit this form (or create your own with the fields below) at the time of initial review and continuing review, or submit it with a Modification Request when adding individuals to the study staff. A. PROTOCOL INFORMATION Version #/Date: Protocol Number: Protocol Title: Principal Investigator or Faculty Advisor / Degree(s): / B. STUDY PERSONNEL. Include here non-Harvard affiliated study personnel that have either 1) contact with human subjects or 2) access to identifiable data, directly or indirectly via a coding system or key. Each of the individuals named below must complete human subjects training (refer to the Investigator Manual or Template Guide (IRB website links below) to learn about training requirements. ONLY LIST PERSONNEL BELOW WHO DO NOT HAVE AN HUID. ALL STUDY STAFF WITH HUIDS ARE TO BE LISTED IN QUESTION 1 OF THE STUDY TEAM MEMBERS PAGE OF THE ELECTRONIC FORM. Does this person have a financial interest Type of Human related to the Name, Degree(s), and Involved Subjects Training research*? If Yes, Non-Harvard Affiliation(s) Role In Study in (Attach to electronic submit “Financial consent? form) Interest Disclosure Form (HRP-221)” Yes No

“Financial Interest Related to the Research” means any of the following interests in the sponsor, product or service being tested, or competitor of the sponsor held by the individual or the individual’s immediate family:  Ownership interest of any value including, but not limited to stocks and options, exclusive of interests in publicly-traded, diversified mutual funds.  Compensation of any amount including, but not limited to honoraria, consultant fees, royalties, or other income.  Proprietary interest of any value including, but not limited to patents, trademarks, copyrights, and licensing agreements.  Board or executive relationship, regardless of compensation. For more information, contact the Office of Technology Department at http://www.techtransfer.harvard.edu .  Reimbursed or sponsored travel of any amount by an entity other than a federal, state, or local government agency, higher education institution or affiliated research institute, academic teaching hospital, or medical center. “Immediate Family” means spouse, domestic partner, children, and dependent children.

Non-Harvard Study Personnel Form | HRP-220 | Version date: September 12, 2013| Page 1 of 1 University Area IRB http://cuhs.harvard.edu/ Longwood Medical Area IRB http://www.hsph.harvard.edu/ohra/