<p> OHR-12A 5/2013 TJU Office of Human Research Adding/Removing JKCCN Sites & Key Personnel</p><p>IRB Control #: Department: PI: </p><p>Study Title: </p><p>Contact Person: Phone/Fax/Email: </p><p>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.</p><p>*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.</p><p>(Check appropriate sites) Added personnel: Removed personnel:</p><p>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 </p><p>Signature of Principal Investigator Date Telephone/pager/e-mail</p><p>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.</p><p>______IRB Official Date of Approval</p><p>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</p>