2022-2023 SRC/IRB MEMBERSHIP ROSTER

2022-2023 SRC/IRB MEMBERSHIP ROSTER

Please complete all applicable sections BEFORE submitting the form.

COMBINED SRC/IRB COMMITTEES require the additional members as noted (IRB/COMBINED).

IF YOU HAVE QUESTIONS OR REQUIRE CLARIFICATION, PLEASE EMAIL scifair@unm.edu.

SCHOOL INFORMATION

SCHOOL NAME*

Please spell out the school name as well as the words "Elementary School", "Middle School", or "High School".

SCHOOL STREET ADDRESS*

SCHOOL CITY*

Please ensure the city name is spelled correctly and begins with a capital letter.

SCHOOL STATE*

Please use the 2-letter state abbreviation.

SCHOOL ZIP CODE*

TYPE OF REVIEW COMMITTEE

TYPE OF REVIEW COMMITTEE*

Please choose the type of committee you will be fielding (SRC, IRB, or COMBINED)

Scientific Review Committee (SRC)

Institutional Review Board (IRB)

COMBINED COMMITTEE (SRC-IRB)

REVIEW COMMITTEE CHAIR INFORMATION

Who have you designated as the Chair of your review committee? The Chairperson MUST also be fully listed in the SRC or IRB/COMBINED members section below!

CHAIRPERSON LAST NAME*

CHAIRPERSON FIRST NAME*

CHAIRPERSON EMAIL*

CHAIRPERSON CELL PHONE*

Phone

PRIMARY CONTACT PERSON INFORMATION

Who should we contact first if there are questions regarding your review committee?

CONTACT PERSON FIRST NAME*

CONTACT PERSON LAST NAME*

CONTACT PERSON TITLE*

CONTACT PERSON EMAIL*

CONTACT PERSON CELL PHONE*

Phone

SCIENTIFIC REVIEW COMMITTEE MEMBERS

These three member types are REQUIRED for all Scientific Review AND Combined Review Committees. The "Science Educator" can be the same person in a Combined Review Committee.

BIOMEDICAL SCIENTIST FIRST NAME

BIOMEDICAL SCIENTIST LAST NAME

BIOMEDICAL SCIENTIST TITLE

BIOMEDICAL SCIENTIST CELL PHONE

Phone

BIOMEDICAL SCIENTIST EMAIL

BIOMEDICAL SCIENTIST DEGREE(s)

Please choose all applicable completed degrees.

Select

BIOMEDICAL SCIENTIST ACADEMIC MAJOR(s)

Please provide the academic major for each completed degree.

EDUCATOR FIRST NAME

EDUCATOR LAST NAME

EDUCATOR CELL PHONE

Phone

EDUCATOR EMAIL

EDUCATOR DEGREE(s)

Please choose all applicable completed degrees.

Select

EDUCATOR ACADEMIC MAJOR(s)

Please provide the academic major for each completed degree.

ADDITIONAL SRC MEMBER FIRST NAME

ADDITIONAL SRC MEMBER LAST NAME

ADDITIONAL SRC MEMBER CELL PHONE

Phone

ADDITIONAL SRC MEMBER EMAIL

ADDITIONAL SRC MEMBER DEGREE(s)

Please choose all applicable completed degrees.

Select

ADDITIONAL SRC MEMBER ACADEMIC MAJOR(s)

Please provide the academic major for each completed degree.

IRB/COMBINED COMMITTEE MEMBERS

IRB/COMBINED SCHOOL ADMIN FIRST NAME

IRB/COMBINED SCHOOL ADMIN LAST NAME

IRB/COMBINED SCHOOL ADMIN CELL PHONE

Phone

IRB/COMBINED SCHOOL ADMIN EMAIL

IRB/COMBINED SCHOOL ADMIN DEGREE(s)

Please choose all applicable completed degrees.

Select

IRB/COMBINED SCHOOL ADMIN ACADEMIC MAJOR(s)

Please provide the academic major for each completed degree.

IRB/COMBINED EDUCATOR FIRST NAME

IRB/COMBINED EDUCATOR LAST NAME

IRB/COMBINED EDUCATOR CELL PHONE

Phone

IRB/COMBINED EDUCATOR EMAIL

IRB/COMBINED EDUCATOR DEGREE(s)

Please choose all applicable completed degrees.

Select

IRB/COMBINED EDUCATOR ACADEMIC MAJOR(s)

Please provide the academic major for each completed degree.

IRB/COMBINED MEDICAL-MH FIRST NAME

IRB/COMBINED MEDICAL-MH LAST NAME

IRB/COMBINED MEDICAL-MH CELL PHONE

Phone

IRB/COMBINED MEDICAL-MH EMAIL

IRB/COMBINED MEDICAL-MH DEGREE(s)

Please choose all applicable completed degrees.

Select

IRB/COMBINED MEDICAL-MH ACADEMIC MAJOR(s)

Please provide the academic major for each completed degree.

FILE UPLOAD

If you have additional members not listed above, please attach a PDF document that lists those individuals along with the same information provided for all other review committee members.

File Upload

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.