IRB Modification Request Form

IRB Modification Request Form

You must have IRB Approval before you can change or modify your research project.

IMPORTANT: Once the IRB Modification Form is complete request a copy be sent to your NMT email for your records. Forward that email to the IRB Admin at irb@nmt.edu

Previous IRB Information

All contact information provided must match the information on original IRB Approval Form.

Primary Investigator Name:*

Department:*

Primary Contact #*

Phone

Primary NMT Email*

Original Project IRB Database Number:*

Numbers only

Title of Project Being Modified*

Funding Source/Agency*

Original Period of Research Project

Project IRB Approval Date:*

Project IRB Expiration Date:*

Modifications Requested

What changes do you need to make?

Changes:*

Choose all that apply

I am requesting an extension to my project’s Expiration Date

I want to make changes or modifications to my research project

Previous Expiration Date:*

New Expiration Date:*

The IRB also asks that you provide a written explanation for these changes. Attach your explanation to this form.

I want to make these changes or modifications:*

The IRB also asks that you provide a written explanation for these changes. Attach your explanation to this form.

Research personnel

Research procedures used

Informed consent documents

Types of human subjects participating

Types of data collected

Principal Investigator/Researcher Assurance*

As principal investigator/researcher, I hereby assure that the information I have provided on this form is correct and accurate, to the best of my knowledge.

Faculty Advisor Assurance*

Is a faculty advisor assurance required?

Yes

Faculty Advisor Assurance*

I understand a signed assurance statement from my faculty advisor is required, including their name, signature, and date, before modifications will be reviewed. It should be attached with this form but can be sent afterwards directly to irb@nmt.edu.

File Upload*

Please attach a brief report describing your changes to the IRB to this form. Attach any other necessary documents here as well.

~Thank you

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Send me a copy of my responses

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