Download this form in PDF 
To: Institutional Review Board for the Protection of Human Subjectss
From: (Name), (Department), (Telephone)
| Title of Research: |
| Previously Assignmed 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 |
