Forms A-Z

Name Description
Access Request - Contingent Worker Employee Use this form to request access to Kuali as an adjunct or pending employee.
Access/Change Request - Current Permanent Employee Use this form to request new access or a change to your existing access if you are a current permanent employee.
Anesthesia/Surgery Record Form to use for all animal surgical procedures.
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Animal Cage Card Form Standard form for animal cage ID and mating cage cards.
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Animal Order Request Form Use this form to order animals and indicate any special instructions.
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Animal Protocol Transfer Form Form to be used to transfer animals from one protocol to another.
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Aquatic anesthesia-surgery record Use this form for anesthesia and surgery records for aquatics (xenopus/fish).
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Assent Form for Children aged 7-12 Use this form when children aged 7-12 are a subject research population, the regulations require the assent of the child or minor and the permission of the parent(s), in place of the consent of the subjects.
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Assent Form for Older Children/Young Adults Aged 13+ Use this form when minors aged 13+ are a subject population in the research project, the regulations require the assent of the child or minor and the permission of the parent(s), in place of the consent of the subjects. Please note that age of majority in MA is 18 but that this varies by state.
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Baystate and UMass Collaborative Human Subjects Form Use this form when researchers from UMass Amherst are collaborating in human subject research with researchers at Baystate Medical Center.
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Conflict of Interest Disclosure Statement - Intellectual Property and Commercial Ventures Form to be used when disclosing a potential conflict related to commercial ventures or intellectual property.
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Contingent Worker Form Use this form to apply for a PeopleSoft HR ID and access to the University electronic systems.
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Cost Share Request Form - AY Faculty Salary When university salary (effort) is committed in a proposal for sponsored funding, faculty must use the Cost Sharing Approval Form to obtain the necessary approvals for the proposed in-kind effort.
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Counseling Resources Guidance Provides guidance on counseling resources for studies on sensitive topics. May be edited as necessary, making sure all contact information relevant to the specific study is accurate and up-to-date.
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Debriefing Form - Deception Guidance on how to ameliorate the effects of unavoidable deception in a research study, the IRB requires debriefing of the deceived subjects.
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Debriefing Form - General Form may be used as a handout to debrief participants on any aspect of a research study considered sensitive.
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Determination of Human Subject Research Form Use this form to provide information to help HRPO determine whether your project requires IRB review. Please note that HRPO makes the determination whether or not a project meets the definition of human subject research.
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Drug-Free Workplace Policy Agreement Agreement signed by the PI acknowledging an awareness of and compliance with the University Drug-Free Workplace Policy. His/her signature also indicates acceptance of the responsibility to inform everyone involved on the project about the Policy. This is a one-time form required by all Principal Investigators before an award can be processed through to Accounting.
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Euthanasia Request Form Form required to request euthanasia as part of a research study.
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Event Tracking Log This worksheet may be used to provide a history of known events for a particular protocol; researchers should maintain an accumulative Non-significant Adverse Event Tracking Log.
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HIPAA Authorization Template Use this form to request access to Health Insurance Portability and Accountability Act (HIPAA) data from individuals.
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Indirect Cost Waiver/Reduction Click on the Document Link to open the form for an Indirect Cost Waiver or Reduction Request Form
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Informed Consent Template - Complex Biomedical - Revised Use this template for complex biomedical research which may necessitate several visits by participants and more than one intervention.
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Informed Consent Template - Focus Group - Revised The consent template to be used when research involves focus groups.
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Informed Consent Template - General - Revised Use this template to compose the Informed Consent document. Instructions specific to items on the form are included in brackets.
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Informed Consent Template - International Affective Picture System (IAPS) - Revised Use this template when utilizing an International Affective Picture System (IAPS) image set. IAPS contains images meant to elicit an emotional response from the research participant. Images are categorized as pleasant, neutral or unpleasant.
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Informed Consent Template - Magnetic Resonance Imaging (MRI) - Revised Use this template if your study uses Magnetic Resonance Imaging.
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Informed Consent Template - Muscle Biopsy - Revised Use this template if your study includes muscle biopsies.
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Informed Consent Template - Online Survey - Revised Use this template if your study involves an online survey research component.
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Informed Consent Template - Paper Survey Consent Paragraph You may use this template if you're conducting a paper survey and are requesting a waiver of documentation of informed consent.
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Informed Consent Template - Sensitive Topics - Revised Use this template for research that involves topics which may be considered sensitive.
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Informed Consent Template - Short Version of Written Consent The oral and short verision of the written consent form is designed to provide a mechanism for individuals with limited English language proficiency to participate in human subject research where their lack of proficiency would otherwise be a barrier to their participation.
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Informed Consent Template - Subject Recruitment Database Use this template if researcher will be asking participants to be part of a subject recruitment database.
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Informed Consent Template - Video Use - Revised Informed Consent form to use for research involving video or audio recordings.
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Informed Consent Template - VO2 Max - Revised Use this template if your study uses V02 Max.
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Late Proposal Approval Request Form The Late Proposal Approval Request form is used to request an exception to the VCRE's mandatory proposal submission procedure.
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Outside Activities - Request for Prior Approval This form should be completed when a faculty member has an outside activity they would like to propose.
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PAR-Q Screener Script Short script to read before issuing the PAR-Q as a screener.
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Parent Permission for Minor to Participate in Research - Revised Use this form to have parents give permission for their child to participate in research.
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Participation Agreement (PAG) Certification required for all first time award recipients.
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Post Operative Record for Lab Animals This form is required for all animals undergoing surgical procedures in addition to the Anesthesia/Surgery Record.
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Pre-establishment of Account Agreement Use this form to request a pre-establishment of account
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Pro Forma Budget Template To be used for Indirect Cost Waiver/Reduction, Cost Share Request, and Request for Voluntary Cost Sharing Forms.
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Professional Name Request Form Use this form to request a name for use on proposals and awards that is different from your legal name.
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Protocol Deviation/Violation Report Form Use this form to report all protocol deviations/violations within 5 business days from the occurrence.
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Recruitment Database Application Form Use this application form to establish a subject recruitment database.
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Reviewer Checklist for Continuing Review This checklist helps reviewers structure the continuing review of approved protocols and maintain consistency in the process.
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Reviewer Checklist for New Protocols This checklist helps reviewers conduct a review of new protocols and maintain consistency in the process.
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SBIR Funding Agreement Since many of the industry partners in the SBIR do not have broad contracting experience, we have found that many partners look to the University for guidance in this area. The following SBIR Funding Agreement has been developed to meet this need.
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Significant Adverse Event Report Form Use this form to report serious and unexpected events related to research under the supervision of the UMass Amherst IRB.
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Sponsor - Subcontractor Request Use this form to request a new Sponsor, Subcontractor, or Prime Sponsor in Kuali.
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STTR Funding Agreement Since many of the industry partners in the STTR do not have broad contracting experience, we have found that many partners look to the University for guidance in this area. The following STTR Funding Agreement has been developed to meet this need.
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Student Consultation Registration Form Use this form if it has been determined that your project requires IRB review and you would like assistance navigating the IRB submission process.
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Sub-Recipient Form Distribute this form to participating entities when setting up a subaward/subcontract/sub-recipient agreement with UMass.
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Subcontract Approval and Sole Source Justification A PI Subcontractor approval sheet and Sole-source Justification if new – used to confirm that the PI approves the subcontract terms and conditions and used to document why this particular subcontractor is solely and uniquely qualified to perform the sub scope of work.
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Summer Salary Waiver Request Form to request a waiver from the Provost's policy on only charging 83.33% summer salary to federal or state sponsored projects.
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Tissue Request Form Use this form when requesting fresh or frozen tissue samples from humans or animals.
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UMass COI/SFI NSF Disclosure form This Conflict of Interest disclosure form should only be used if a PI is applying for funding from the National Science Foundation (NSF).
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Unanticipated Problem Report Form Use this form to report unanticipated problems involving risks to subjects or others related to your IRB approved research.
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Vertebrate Animal Classroom Use Bringing vertebrate animals from an off-campus source into a UMass classroom or UMass property may require review and approval by the Institutional Animal Care and Use Committee (IACUC). You will either be required to complete an IACUC protocol https://umaeprotocol.research.umass.edu/umas/ or describe the proposed use on this short form.
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