Clinical Trial Informed Consent Waiver Request Form
Study Information
Study Title
Protocol Number
Principal Investigator Name
Contact Information
Institution
Waiver Request Details
Type of Waiver Requested
Informed Consent Waiver
Documentation Waiver
Justification for Waiver Request
Risk Assessment (Minimal Risk Justification)
Measures to Protect Privacy and Confidentiality
Additional Information
Explanation of Why the Research Cannot Practicably Be Carried Out Without the Waiver
Public Benefit Statement (if applicable)
Other Relevant Information
Principal Investigator Signature
Date