California State University, Long Beach

Institutional Review Board for the Protection of Human Subjects

APPLICATION FOR MINOR CHANGE or MODIFICATION
to an Active Approved Protocol

(rev. 7/1/00)

TO: Institutional Review Board for the Protection of Human Subjects

FROM: (name)
(department)
(telephone)

TITLE OF RESEARCH:

PREVIOUSLY ASSIGNED PROTOCOL NUMBER:

PREVIOUS REVIEW TYPE: (Circle/Underline one) Standard Expedited Exempt

PREVIOUS DURATION (DATES) OF ACTIVITY: Begin End

PROPOSED CHANGE OR MODIFICATION:

BRIEF EXPLANATION OF REQUEST:

_________________________________________________
Signature of Researcher and Date

IRB USE:

____________________________________________________
Senior Associate Director, Office of University Research and Date