Quorum Review IRB - 2011 Price List

For completion by Quorum staff
PI name / QR number
Sponsor / Protocol number
Paper consent form corresponding to e-consent / Title / Version / Board approval date

E-consent certificate

§  A separate certificate is required for each e-consent.

§  An e-consent is a digital representation of a Board-approved paper consent form. It is designed for use by study participants on computers, tablets, or other electronic devices. An e-consent can include audio, video, or other multimedia content.

Background information

E-consent company
Primary contact
for e-consent / Name / Title
Name of e-consent device(s)
Name of e-consent platform system(s)
E-consent: Title, version, and date submitted to Quorum Review
Title / Version / Date submitted

Attestation

I hereby certify that the e-consent referenced above is, to the best of my knowledge and belief, a true and accurate representation of the corresponding paper consent form (listed above) in electronic format (including any audio, video, or other multimedia component that is part of the electronic format). The e-consent is identical to the corresponding paper consent document except for the differences noted in the attached list.
Signature / Date
Name of company that employs signee
Printed/typed name of signee / Printed/typed job title of signee

On the next page, please provide a list of deviations between the e-consent and the corresponding paper consent document.

Differences between the e-consent and paper consent form

In the table below or in an attachment:

§  Please list and describe differences between the e-consent and the corresponding Board-approved paper consent form.

§  Please note the location of each difference by doing one of the following (as applicable):

§  Cite the page number of the paper consent form related to the difference (such as a difference in wording between the paper consent form and the consent form text as incorporated into the e-consent).

§  Cite “General” if the deviation is an overarching difference (such as the presence of supplementary educational elements in the e-consent that are not present in the paper consent form).

List of differences

Number / Description of difference / Location of difference
Paper document page number or “General”
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10. 

Please add additional rows or provide an attachment as needed.

F-140-001.1, E-Consent Certificate, 01Dec2013 / Page 2 of 2