IRB Expedited Review Application Form

1. Principal Investigator Information

Name Email Department / Affiliation Phone

2. Study Title

3. Research Team Members

Name(s) & Role(s)

4. Project Dates

Expected Start Date Expected End Date

5. Funding Source

Funding Source (if any) Grant Number (if applicable)

6. Study Description

Purpose of Study Study Procedures Subject Population (age, gender, number, inclusion/exclusion criteria)

7. Expedited Review Category

Please specify the category (per 45 CFR 46.110)

8. Risks and Benefits

Potential Risks to Subjects Potential Benefits to Subjects/Society

9. Informed Consent Process

How will consent be obtained?

10. Privacy and Confidentiality

Describe privacy/confidentiality protections

11. Data Collection & Storage

Data Collection Methods Data Storage and Security

12. Attachments Checklist

Study Protocol Consent Forms Recruitment Materials Surveys/Questionnaires Other (specify)

13. Certification

I certify that the information provided is complete and accurate. Name Date