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UNC Research » IRB and the Office of Human Research Ethics » IRB Member Application Form

IRB Member Application Form

To be completed for all initial and reappointments to the IRB.

"*" indicates required fields

Name*

First Middle Last

Prefer to be Called by:

Date Completed*

Month

Day

Year

Select one:*

I am affiliated with UNC*

I am NOT affiliated with UNC

*i.e., full time and part-time employees; immediate family of employee, retiree, current students; members of any governing panel or board of the institution; paid or unpaid consultants; healthcare providers holding credentials to practice at the institution; and volunteers working at the institution on business unrelated to the IRB

Nature of affiliation

If not affiliated with UNC-CH, who is your employer?

What is your expertise and background?*

Please attach a copy of your most recent CV/Resume.*

Max. file size: 50 MB.

Mailing Address*

Please use the address where you would like IRB mail sent.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Your Department/Division*

CB #

Preferred Email*

Phone Number*

Cell Phone/Pager Number*

What is the best way to reach you?*

PID*

If you are non-affiliated, a PID# will be assigned after a background check has been completed.

PID

If you are non-affiliated, a PID will be assigned after a background check has been completed.

ONYEN*

Onyen

If you are non-affiliated, you will be able to create an onyen after you are assigned a PID.

All members need an ONYEN, UNCʼs campus-wide electronic service identifier, in order to access study information in IRBIS (UNCʼs IRB Information System). To obtain an ONYEN, you must first obtain a PID (Personal ID Number), a unique identification number assigned to each person with a University relationship.

Date of Birth*

Month

Day

Year

Degrees earned:*

If MD or other licensed or credentialed professional, what license do you hold and in what year were you licensed or credentialied?

Please list area(s) of speciality, and whether these are scientific or nonscientific.*

If Researcher, in what year did you begin conducting research?

Please briefly summarize your research experience.*

Please tell us why you are interested in joining the UNC Institutional Review Board (IRB).*

Please list any real life experiences that you have had that will assist you in evaluating research in areas other than your professional expertise.*

(e.g., scout leader, social organizations, caring for elderly parents, working with children)

Name of person who recommended you for IRB membership

Primary or Alternate?*

A Primary Member attends the majority of the IRB Meetings to the board to which he/she is assigned.

An Alternate Member is on call for when your expertise is needed.

What is your availability?*

Com A Meets the 1st Monday of the Month. The meetings start at 1pm and go until done (Usually 5pm).

Com B Meets the 2nd Monday of the Month. The meetings start at 1pm and go until done (Usually 5pm).

Com C Meets the 3rd Monday of the Month. The meetings start at 1pm and go until done (Usually 5pm).

Com D Meets the 4th Monday of the Month. The meetings start at 1pm and go until done (Usually 5pm).

Com E Meets the 2nd Tuesday of the Month. The meetings start at 1pm and go until done (Usually 5pm).

Com F Meets the 4th Thursday of the Month. The meetings start at 1pm and go until done (Usually 5pm).

Alternate- Flexible – On Call as Needed

What date would you be available to start?*

Month

Day

Year

Demographics: Optional

Primary Language

Secondary Language(s)

Fluency

Fluent

Not Fluent

Ethnicity

Race

Gender

For University of North Carolina at Chapel Hill Employees Only

Supervisor Name

Supervisor Title

Department Name (and/or Program Name, if Applicable)

Supervisor CB#

Supervisor Email Address

Has your supervisor given their permission for you to serve on the IRB?

Written permission is not required.

Yes

What is the name, phone # and email address for your departmental contact for salary support?

Salary support is currently only offered to University Faculty Positions.

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Comments

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IRB Member Application Form

IRB Member Application Form

Demographics: Optional

For University of North Carolina at Chapel Hill Employees Only