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HRPP Policies & Forms Chapter Two. Created/Revised for AAHRPP June 1, 2007. REVISED POLICIES. Revised Policy. SOP 202 Management of IRB The performance of the IRB Chairs, Vice Chairs, and IRB Members shall be evaluated on an annual basis.

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HRPP Policies & Forms Chapter Two

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hrpp policies forms chapter two

HRPP Policies & Forms Chapter Two

Created/Revised for AAHRPP

June 1, 2007

revised policy
Revised Policy

SOP 202

Management of IRB

The performance of the IRB Chairs, Vice Chairs, and IRB Members shall be evaluated on an annual basis.

This periodic evaluation is conducted to assess performance taking into consideration, completion of education requirements, attendance, preparedness, knowledge and abilities in applying the ethical principles and regulations governing human research, and knowledge of IRB policies and procedures.

newly created forms
Newly Created Forms

Chair/Vice Chair Evaluation Form

Board Member Evaluation Form

revised policy5
Revised Policy

SOP 403

Initial Review - Criteria for IRB Approval

The IRB shall evaluate proposed research for scientific or scholarly validity based on the following:

  • Whether the research uses procedures consistent with sound research design, which did not unnecessarily expose participants to risk.
  • Whether the research is designed to answer the proposed question.
  • The importance of the knowledge reasonably expected to result from the research.
revised policy6
Revised Policy

SOP 404

Continuing Review

As an outcome of continuing review, the IRB may require that the research be suspended or terminated as per SOP 411 Suspension or Termination of IRB Approval.

As an outcome of continuing review, the IRB may require that any significant new findings that arise from the continuing review process and that might relate to participants’ willingness to continue participation will be provided to participants.

revised policy7
Revised Policy

SOP 407

Unanticipated Problems Involving Risks to

Participants or Others & Protocol Deviations

  • When a deviation occurs, the Investigator completes the protocol deviation form.
  • The Investigator determines if the protocol deviation meets the definition of an unanticipated problem according to the criteria indicated on the deviation form and submits the form to the IRB.
sop 407
SOP 407
  • If the IRB Chair determines that the protocol deviation is an unanticipated problem involving risks to participants or others or resulted from serious or continuing noncompliance, the deviation report will be reviewed at an IRB meeting.
  • If the IRB Chair determines the protocol deviation does not meet the criteria of an unanticipated problem, the deviation will be reviewed by the expedited procedure.
revised form
Revised Form

Protocol Deviation Report Form

revised policy10
Revised Policy

SOP 502G

Emergency Use of FDA Regulated Products

Planned emergency research is defined as planned research involving a life-threatening emergency where the requirement to obtain prospective informed consent has been waived.

The research plan must be approved in advance by the FDA or DHHS and the IRB, and project, as well as its results, are publicly disclosed to the community in which the research is conducted.

sop 502g
SOP 502G

The IRB will not review and waive the requirement to obtain consent for planned emergency research. Therefore, no planned emergency research can be conducted at OU.

revised policy12
Revised Policy


IRB Communication and Notification

Notification to Institutional Offices and Officials

The HSC IRB shall notify the HSC Office of the Provost, Senior Vice President and Provost as Institutional Official of IRB findings and actions. The Institutional Official shall receive a copy of the IRB meeting minutes for each IRB.

sop 601
SOP 601

Questions, Concerns and Suggestions Regarding the

Human Research Participant Protection Program

  • Investigators can direct questions, concerns and suggestions regarding the Human Research Participant Protection Program to the HRPP Director.
  • Investigators can direct questions, concerns and suggestions regarding the Human Research Participant Protection Program that cannot be satisfactorily addressed by the HRPP Director to the Director of Compliance or the Institutional Official.
revised policy14
Revised Policy

SOP 70l

Consent Process & Documentation

Waiver of Documentation of Informed Consent

If documentation of informed consent is waived, theInvestigator will ask whether the participant wants documentation linking the participant with the research, and the participant’s wishes will govern.

sop 701
SOP 701
  • If the IRB waives the requirement of documentation of informed consent, the IRB may require the investigator to provide a written statement of the research to the participant.
  • The IRB shall review and approve the written statement prior to the investigator providing the statement to the participant.
  • The consent form reviewed and approved by the IRB may also serve as the written statement.
sop 70116
SOP 701

Legally Authorized Representative

For research conducted outside of Oklahoma, individuals who meet the definition of a legally authorized representative are those individuals as described under the applicable law of the jurisdiction in which the research will be conducted.

If recruiting a participant from a legally authorized representative the investigator must report this category of participant on the IRB application and provide to the IRB the definition of legally authorized representative for the applicable jurisdiction.

revised policy17
Revised Policy

SOP 901

Quality Improvement

Investigator-initiated studies, where the investigator holds an IND/IDE, are the primary targets of routine evaluation.

When assuming the role of the sponsor, the investigator is evaluated to ensure compliance with the additional regulatory requirements as outline in SOP 802 Sponsor Responsibilities and good manufacturing practice.

sop 901
SOP 901

The investigator is required to submit an annual report to the FDA and is notified by the IRB sixty days in advance of its due date. Compliance with this requirement is monitored by the IRB staff via the continuing review application.

sop 90119
SOP 901

Observation of the Consent Process

The IRB has the authority to observe, or have a third party observe, the informed consent process of research it has approved, and to verify that the study is being conducted as required by the IRB and within the institutional policies and procedures and site-specific procedures, as appropriate.

Before the IRB or third party observes the consent process, verbal consent of the participant may be sought.

sop 90120
SOP 901

The IRB may determine it is necessary to observe the

informed consent process in order to provide additional

protections and may conduct informed consent

observations in the following situations:

  • Non-compliance per SOP 903,
  • Unanticipated problems involving risks to participants or others per SOP 407,
  • Protocol deviations as per SOP 407,
  • Participant complaints, or
  • or any other situation the IRB deems appropriate where additional protections are necessary.
consent observation
Consent Observation

Informed Consent Observation Checklist

sop 90122
SOP 901

IRB Internal Evaluations/Improvement Plan

The HRPP shall measure and improve the program’s effectiveness, quality, and compliance with organizational policies and procedures and applicable federal, state, and local laws.

sop 90123
SOP 901

IRB Internal Evaluations

  • Improvements to the HRPP program shall be implemented based upon measures identified through routine evaluations of the program. These improvements include education programs, IRB member and staff training, revising Policies and Procedures, and form changes.
  • The improvements shall be monitored and measured to determine effectiveness. If necessary, additional improvements shall be implemented.
va specific revisions
VA-Specific Revisions

Consent Requirement

If someone other than the investigator will be conducting the interview and obtaining consent, the investigator must formally delegate the responsibility to an individual who has received appropriate training to perform this activity.

va specific revisions26
VA-Specific Revisions

For VA research the legally authorized representative is

defined as the following persons in the following order of


  • Health-care agent.
  • Legal guardian or special guardian.
  • A close relative of the patient eighteen years of age or older, in the following priority: spouse, adult child (18 years or older), parent, sibling (18 years or older), grandparent, adult grandchild (18 years or older), close friend (18 years or older).
va specific revisions27
VA-Specific Revisions

Exempt Research Category #2

Research involving the use of educational tests (cognitive,

diagnostic, aptitude, achievement), survey procedures,

interview procedures, or observation of public behavior,


  • Information obtained is recorded in such a manner that human participants can be identified, directly or through identifiers linked to the subjects; and
va specific revisions28
VA-Specific Revisions

Exempt Research Category #2

  • Any disclosure of the human participants' responses outside the research could reasonably place the participants at risk of criminal or civil liability or be damaging to the participants' financial standing, employability, or reputation. NOTE: The Department of Veterans Affairs (VA) also includes loss of insurability in this category.
va specific revisions29
VA-Specific Revisions

Continuing Review

For VA research that expires because continuing review is not completed the IRB shall notify the sponsoring agency, private sponsor, Office of Research and Development, Office of Research Oversight, or other Federal agencies, as appropriate.

va specific revisions30
VA-Specific Revisions

Drug Dispensing & Accountability

  • The investigator shall provide the pharmacy with a signed copy of the VA Form 10-1086 to document each participant’s consent to participate in the study.
  • The Investigator shall inform the Chief, Pharmacy Service, and the R&D Committee when the research has been terminated.
sponsored research agreements
Sponsored Research Agreements

Contracts shall:

  • Identify who is responsible to provide and pay for medical care for research-related injuries.
  • Include language stating the sponsor will promptly notify the organization of any study results or findings that could affect the conduct of the study, participant safety, participant’s willingness to continue in the study, or the IRB’s approval to continue the study.
revised forms
Revised Forms
  • New Research Project Application
  • Determination of Human Research Worksheet
revised consent template
Revised Consent Template

Consent Template

revised reviewer checklists
Revised Reviewer Checklists
  • New Study Reviewer Checklist
    • Full Board Review
    • Expedited Review
    • Exempt
  • Continuing Review Checklist
  • VA Criteria
  • Waiver of Consent
effective date
Effective Date

June 1, 2007