Behavioral Health Study
Informed Consent Waiver Request

1. Study Information

Study Title Principal Investigator Institution/Department Contact Information Protocol Number (if applicable)

2. Description of the Study

Provide a brief summary of the research project:

3. Request for Waiver of Informed Consent

Describe the reason for requesting an informed consent waiver:

4. Justification for Waiver (45 CFR 46.116 Criteria)

1. Explain how the research involves no more than minimal risk to participants:
2. Explain why the waiver will not adversely affect the rights and welfare of participants:
3. Explain why the research could not practicably be carried out without the waiver:
4. Explain, if appropriate, how pertinent information will be provided to participants after participation:

5. Additional Information

Include any additional information relevant to the waiver request:

6. Certification

Name of Principal Investigator Date