1. POLICY IRB members rely primarily solely on the documentation submitted by investigators for initial and continuing review. Therefore this material must provide IRB members with enough information about a study to assess whether it adequately meets the IRB s regulatory criteria for approval. A submitted protocol will be scheduled for IRB review when RSPP staff has determined that the information and materials submitted present an adequate description of the proposed research or action. Specific Policies Terms used in this policy, but not defined herein shall have the meanings set forth in the Glossary. 1.1. Submission Requirements for Initial Review Submissions to the IRB are accepted in two formats: paper Microsoft Word/PDF (via e-mail) or the Cyber IRB electronic method. Both formats require that the same documents be included with the submission. The difference between submission formats is in the number of copies that must be included with the submission, and the need for the whether an original or electronic signature on an applicable document is acceptable. Cyber IRB will allow any and all required documents to be uploaded electronically in a web-based system. with the submission application.the submission application is completed online. It and all uploaded documents are made available to the RSPP office electronically. The Cyber IRB format requires that the PI provide an electronic signature for submission. Cyber IRB is 21 CFR part 11 compliant which allows for electronic signature of documents. The Microsoft Word/PDF format requires that all submission documents (submission form and others) be sent to the IRB office as Microsoft Word or PDF files (depending on the document type). This can be accomplished by attaching all documents to an email sent to the RSPP office. The Word/PDF format requires the PI to sign the submission form prior to sending to the IRB office as a scanned document (PDF). 1.1.1. Required: Initial applications must include: Steering Committee approved / effective date: 2/2511 Clearance from Aurora s Senior Vice President of Research (or designee) to conduct the human subject research project.
IRB Submission Application (Form FO 301-A or FO 302-A) in sufficient detail to allow the IRB to ascertain that a study meets the regulatory criteria for approval. Applications completed in the paper-based system format, must be signed by the Principal Investigator and the original signature must be on file in the RSPP office. For Cyber IRB submissions, electronic signature is acceptable as Cyber IRB is 21 CFR part 11 compliant. If applicable, the complete Rresearch protocol from the sponsor indicating that includes version date or tracking informationor revision numbers PROTOCOL template (including sponsor s ssample informed consent document). If applicable, the Investigator Brochure (investigational drug or biologic), Package Insert (approved drug) or Device Operator Manual /Instructions for Use or device specifications and that includes the version date or tracking information of such brochure or manual. If applicable, any data collection tools, surveys, questionnaires, assessment instruments, and case report forms to be used. If applicable, proposed local informed consent/authorization document containing all required elements required by federal regulationsof informed consent, as well asand those additional elements as when appropriate, using the Aurora IRB-approved template as a guide. All materials to be received or reviewed by subjects (e.g., diaries, blister packs, instruction sheets, videos). Any proposed recruitment materials (e.g., advertisements, letters, phone scripts, Dear Doctor letters, etc.) to be used. (See also Policy RR 406). If the study is federally funded, and Aurora is the funding recipient (i.e. the awardee ) of the grantan the awardee, a copy of the grant/ proposal (including the budget pages DO WE NEED BUDGET?? but without the appendices) must be submitted for reviewto the RSPP office. A copy of the grant application/ or proposal will be retained by the RSPP Office in the study file. The Primary reviewer and the IRB will review the grant/proposal, and the
meeting minutes will document such reviewand made available to any IRB member who may wish to review it. The grant application/proposal will be reviewed by the Primary Reviewer in accordance with OHRP guidance by the Primary Reviewer. Copy of the Principal Investigator s current CV or other supporting material evidencing clinical privilegesshowing sufficient expertise necessary to conduct proposed research study. Conflict of Interest Statement (GA 104-A) signed by each investigator and key personnel listed on the submission application. Applications completed in the paper format must include an original signature on each COI form. The original form for each investigator will be kept on file in RSPP office. Applications completed in Cyber IRB do not require an original signature on the COI form. A scanned copy of the signed form may be uploaded with the Cyber IRB submission application. [Note that COI forms are not required for studies that qualify for exemption from IRB review (see policy FO 302)]. Delegation of Authority log (RR 402-C). Note: Prior to submission to the Aurora IRB, Aall investigators and key personnel listed on the submission application are required to have completed a current interest disclosure statement in COI Smart as required by AHC system policy #269. They are also required to hold Research Certificationcomplete the training requirements found in hold Research Certification (policy GA 102) (section 1.1) prior to issuance of the final approval letter. The Principal Investigator must have completed the Research Certification process prior to the submitting the protocol for review. 1.1.2 In addition, the following items are required if when applicable: Delegation of Authority log. The DHHS-approved sample consent document (when one exists). The ccomplete DHHS-approved protocol. (when one exists). Copy of the signed FDA Form 1571, 1572 (IND) or signed Investigator Agreement (IDE).
If the study involves a Significant Risk device, Investigation Device Exemption (IDE), a copy of FDA s Investigational Device Exemption (IDE) letter giving clearance to begin the study. If the study involves an unapproved drug or a drug being studied for a new indication investigational drug (i.e. an IND number has been assigned the study drug), the IND number should be printed on the sponsor protocol. If not, and the IND number is not stated in the sponsor s protocol, a copy of the FDA s acknowledgment letter noting the IND number issued assigned to the drugprotocol, OR a letter from the sponsor stating that the IND number provided on the submission application form is the correct IND number for the drug being investigated in and the study protocol under review must be provided. If the protocol meets the criteria for an IND exemption, the sponsor must provide the IND Exemption letter from the FDA, or justification regarding the IND Exemption for IRB concurrence. ation that the study has been reviewed and approved by other appropriate committees/entities (such as Radiation Safety, Institutional Biosafety Committee, etc.) IRB fform SC 502A (see Policy SOP SC 502) for Preparatory to Research Activities or to when requesting a wwaiver of HIPAA authorization. Applications completed in the paper format must include an an the original signature by of the Principal Investigator. The original form will be filed in RSPP office. Applications completed in Cyber IRB do not require an original signature. A scanned copy of the signed form may be uploaded with the Cyber IRB submission application. Any investigator who does not meet the definition of Affiliated with Aurora set forth in section 1.1.1 of Policy SC 502, must have the support and assistance of a Facilitator (see section 1.5 below) who is Affiliated with Aurora, prior to submitting a research request or other related activity to the IRB. 1.2. Requirements for Ongoing Monitoring of IRB Approved Research 1.2.1. During the approval period, the IRB is required to conduct ongoing monitoring of the research study (see Policy SOP RR 403). Investigators must promptly submit documentation to inform the IRB about problems, issues, new information, and study status changes in the status of the study including, but not necessarily limited to the following, as noted in SOP 403:
Significant protocol violations; (as defined in Policy RR 403) must be reported to the IRB on Form RR 403-G.; Reports of Unanticipated Problems, as defined in Policy RR 403, must be reported to the IRB on Forms RR 403-A or RR 403-B, as applicable;. Significant new findings (DSMB reports, annual reports, updates to investigator brochures, etc.) must be reported to the IRB on Form RR 403-F.; Amendments and/or changes to the research study (including temporary holds on enrollment or enrollment closures), protocol or informed consent document must be reported to the IRB using the IRB Modification form (Form RR 403-C);. Investigators must obtain IRB approval before undertaking any change to the approved protocol, except where necessary to eliminate apparent immediate hazards to human subjects. Notification that a study has been completed and the IRB file may be permanently closed must be reported to the IRB using the Continuing Review Report/Final Report Form (Form RR 404-ASee SOP 404). 1.2.2. Continuing Review Report to Request Renewal of IRB Approval. Renewal of IRB approval of the study must be done at least annually per SOP 404 utilizing the Continued Review Report/Final Report Form (RR 404-A). The IRB office will notify the investigator that continuing review is due in accordance with Policy RR-404. Investigators must submit: A completed Continuing Review Report/Final Report Form (Form RR 404-A). All the required materials as indicated on the form. 1.3. Action Taken If ation is Not Adequate or Additional Information is Required If the IRB, IRB Chair, or RSPP staff Director/Staff determine that the submitted documents are not adequate, Investigators may will be required to submit additional information, or the study may be returned to them for revisions. No incomplete submission will be reviewed by the IRB.
The presence of the Investigator (or his/her representative) is recommendedmay be requested at the IRB meeting in order for him/her to answer address any questions by the IRB or explain the details of the study. 1.4. Access to RSPP Study File Materials Access to the study file contents will be limited to the IRB members, RSPP staff, and others as determined appropriate by the RSPP Manager Director (e.g., study staff, ARI Quality review staff, representatives from regulatory agencies and accrediting agencies, etc.). Each individual who accesses the RSPP study file must complete the Access Log (FO 301-C). Individual requests must be made to the IRB office in advance. The RSPP Manager Director will determine whether access to the files is allowed. 1.5. Research Facilitator Any individual who is not Affiliated with Aurora that is, he/she is not an employee, a member of the medical staff or an allied health professional on the medical staff, of an Aurora Facility or a hospital, clinic, physician group or other entity that has entered an affiliation agreement with an Aurora Facility must have the support and assistance of a Facilitator prior to submitting a project for review by the Aurora IRB. The submission form has a place to document the name and signature of agreement of the designated Facilitator. 1.4.1.1.5.1. Facilitator Credentials Aurora Health Care employees or physicians on the medical staff or an allied health profession on the medical staff of any Aurora hospital Facility may serve as an Aurora research facilitator, if they meet the following requirements: a certificate of completion for the NIH tutorial is on file with the Aurora RSPP office hold Research Certification (see SOP GA 102); obtain their manager s approval (if applicable); are familiarity with Aurora IRB policies and guidelines; and be a physician or doctoral level scientist, or have a master s degree. 1.4.2.1.5.2. Facilitator Responsibilities The research facilitator will:
direct the investigator (who does not meet the definition of Affiliated with Aurora ) to appropriate managers or administrators to seek administrative approval (e.g. clinical units, Clinical Research Department, Radiology Department, etc.) and contractual agreements (if applicable) for the study (e.g. clinical units, Clinical Research Department, Radiology Department, etc.); direct the investigator to appropriate Aurora IRB policies related to research conduct and to other system-wide policies applicable to research; facilitate integration of the research into the clinical operations of the appropriate units or propose additional budgeting to subcontract study management outside of the Aurora clinical staff s workload (e.g. possibly with the Clinical Research Department, CV Research Department, or Imaging Research Departmentvia Aurora Research Institute); and review the entire submission packet and sign the final version of the Aurora IRB submission form. 2. SCOPE These policies and procedures apply to all research submitted to the IRB. 3. APPLICABLE REGULATIONS, GUIDELINES AND STANDARDS 45 CFR 46.115 21 CFR 56.108(a)(4) 21 CFR 312, 812 ICH Good Clinical Practice (GCP) Guideline AAHRPP Elements II.2.D., II.2.E., and II.3.C.1. 4. REFERENCES TO OTHER APPLICABLE SOPS This SOP affects all other SOPs.