Award for Excellence in Human Research Protection
Judges application form

Please complete and fax this form to 301-320-0978 (or email to
Submit resume or brief biographical sketch highlighting relevant qualification & experience.

Award for Excellence in Human Research Protection recognizes demonstrated excellence and innovation in human research protection. There are 3 Award categories:

Health Improvement Institute invites participation on volunteer panels to judge applications for an Award. The deadline for receipt of Award application is the last Monday of September. Judges must complete their evaluations by the end of October.

Please complete and fax to 301-320-0978 - page 1 of ____ Click for PDF format

Name: _____________________________________________________________________________
Organization: _____________________________________________________________________________
Position/Title: _____________________________________________________________________________
Address: _____________________________________________________________________________
Telephone: __________________________ Fax: ______________________________________________
Email: _____________________________________________________________________________

Please complete below and sign at end.

1. Please check the one category that is most applicable:

1.1 Present organization:  
Accrediting organization Health professional association (e.g., AMA, ANA)
Consumer advocacy organization Independent consultant/Individual
Drug/device manufacturer Law firm
Government/regulatory agency Research performer - center/institute/university
Healthcare facility (e.g. hospital) Research sponsor/funder
Health plan/insurer Voluntary health association (e.g., Red Cross)
Health trade association (e.g., AHA, BIO,  PHARMA) Other, please specify below:
1.2 Present role in research enterprise:  
Administrator (of research institution/center) Proposal/study reviewer - ethics
Consumer/research participant advocate Proposal/study reviewer - science
Consultant to IRB/HRP program Public relations/communications professional
Educator/trainer Regulator (government)
HRP compliance officer/auditor Social scientist (who studies the enterprise)
HRP professional/IRB staff Study administrator/coordinator
HRP QI/CQI committee member Study monitor/auditor/evaluator
Investigator/researcher Study staff
IRB/ethics committee member Surveyor (accrediting organization)
Journal reviewer (ethics/science) Other, please specify below:
2. Research experience 5. Human research protection experience -
2.1 For how many years have you been actively     In the past 5 years, in which of the following
     involved in the human research enterprise     ways have you protected human subjects of
     (excluding years that you were not fully involved)?     research?
     _____ Check all that apply
  Conflict of interest committee
2.2 How many of the last 5 years have you been Consumer/participant advocate
     actively involved in the human research Consultant to IRB/HRP program
     enterprise in a role relevant to the HRP compliance officer/auditor
     protection of people who participate in HRP program oversight
     research studies? _____ HRP QI/CQI committee
  checkbox Investigator/researcher
2.3 What type of human research have you done, IRB/ ethics committee - member
      and for how many years (excluding years IRB/HRP program - staff
     that you were not fully involved)? Journal reviewer (ethics/science)
     Check all that apply Proposal/study reviewer - ethics
      None Proposal/study reviewer - science
      Behavioral research, surveys, etc; Regulator (government)
          _____years Scientific integrity committee
      Clinical (biomedical) research; _____ years Study administrator/coordinator
      Other, specify below; _____ years Study monitor/auditor/evaluator
      _____________________________________ Study staff
  Surveyor (accrediting organization)
3. Certifications - Which of the following types of Other, specify: __________________________
    certification (given by a recognized professional
    body) do you hold? Check all that apply 6. Adverse professional events - In the last
    IRB professional     5 years, have you been, or are you currently,
    Research administrator    involved with any event that could call
    Other relevant certification, specify    into question your suitability to be a
    _____________________________________    judge (e.g., adverse action regarding quality
     of care, professional conduct, research
4. Human research protection (HRP) training    integrity, etc)?
4.1 In the past 5 years, which of the following      Yes; explain below      No
     types of formal training (e.g., regarding  
     federal regulations) have you completed 7. Comments - including any other relevant
     successfully? Check all that apply qualifications or experience, explanations of
      Investigator adverse professional events, etc.
      Institutional official  
      IRB member  
      IRB staff/support  
      Research staff (including, e.g., CRO)  
      Surveyor (for HRP accreditation)
      Training of trainers
      Other, specify: __________________________
4.2 Have you received formal training in the last
     5 years or are you knowledgeable about
     current federal regulations pertaining to:
      Protecting human subjects of research?
          Training in last 5 yrs Knowledgeable No
      Assuring the integrity of research?
          Training in last 5 yrs Knowledgeable No

Signed: ______________________________________________ Date: ____________________

Printed name: ___________________________________________________________________

version 2.1; revised February 18, 2008