Genomic Data Research Informed Consent Waiver Request
Protocol Information
Protocol Title
Principal Investigator
Protocol Number
Date of Submission
Research Description
Briefly describe the purpose of the research involving genomic data
Justification for Waiver of Informed Consent
State why it is not practicable to obtain informed consent from participants
Describe steps taken to minimize risks related to privacy and confidentiality
Explain if and how the rights and welfare of participants will be protected
Genomic Data Details
Type(s) of genomic data to be used
Source(s) of genomic data
Will data be shared with third parties? If yes, explain
Additional Information
Include any other relevant information supporting the waiver request
Investigator Certification
Name
Signature
Date