Pediatric Population Research Informed Consent Waiver Request

Study Information

Study Title Principal Investigator IRB Protocol Number

Waiver Request Details

Describe the research involving the pediatric population Justification for Waiver of Informed Consent Risk Assessment (Describe risks to participants and how risks are minimized)

Regulatory Criteria

Why is it not practicable to obtain consent? (Include explanation) Describe how the waiver does not adversely affect participants' rights and welfare

Additional Information

Plan for providing additional information to subjects (if appropriate)

Name of Person Completing Form Date