Forms

Animal Care/Use
Name Description
Anesthesia/Surgery Record Use this form for animal surgical procedures. For Aquatics, use the form below this titled Anesthesia/Surgery Record - Aquatics.
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Anesthesia/Surgery Record - Aquatics Use this form for anesthesia and surgery records for aquatics (xenopus/fish).
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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 (non-Rodent or Rabbit) Use this form to order animals (non-rodents or rabbits) and indicate any special instructions.
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Animal Order Request Form (Rodents & Rabbits) Use this form to order animals (rodents and rabbits) 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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Euthanasia Request Form Form required to request euthanasia as part of a research study.
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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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Tissue Request Form Use this form when requesting fresh or frozen tissue samples from humans or animals.
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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 or describe the proposed use on this short form.
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Animal Subjects/IACUC
Name Description
Anesthesia/Surgery Record Use this form for animal surgical procedures. For Aquatics, use the form below this titled Anesthesia/Surgery Record - Aquatics.
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Anesthesia/Surgery Record - Aquatics Use this form for anesthesia and surgery records for aquatics (xenopus/fish).
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Animal Order Request Form (Rodents & Rabbits) Use this form to order animals (rodents and rabbits) 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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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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Tissue Request Form Use this form when requesting fresh or frozen tissue samples from humans or animals.
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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 or describe the proposed use on this short form.
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Award Related
Name Description
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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Pre-establishment of Account Agreement Use this form to request a pre-establishment of account NOTE: Must use netid@umass.edu to log in. Extended email suffixes not supported (i.e. netid@research.umass.edu)
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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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Budget
Name Description
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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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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Compensation/Effort
Name Description
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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Compliance
Name Description
Animal Cage Card Form Standard form for animal cage ID and mating cage cards.
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Assent Form for Adults with Cognitive Impairments Assent form for adults with cognitive impairments. Please NOTE: this is NOT a consent form. This form is for people working with adults who have cognitive impairments such that they cannot sign a consent form themselves, and will need to get consent from that person's caretaker, parent, guardian, etc.
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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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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 Provide information in Kuali 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.
HIPAA Authorization Template Use this form to request access to Health Insurance Portability and Accountability Act (HIPAA) data from individuals.
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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 - iDXA Use this template if your research involves iDXA.
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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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Outside Activities - Request for Prior Approval OA form for faculty with no federal funds.
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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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Recruitment Database Application Form Use this application form to establish a subject recruitment database.
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Reviewer Checklist for Amendments Reviewer Checklist for IRB Members to document their review and analysis of Full Board protocols reviewed by the convened IRB. The Reviewer Checklist helps ensure that all required elements of the federal criteria for approval are met.
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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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Reviewer Checklist for Renew/Amends Reviewer Checklist for IRB Members to document their review and analysis of Full Board protocols reviewed by the convened IRB. The Reviewer Checklist helps ensure that all required elements of the federal criteria for approval are met.
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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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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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Conflict of Interest
Name Description
Outside Activities - Request for Prior Approval OA form for faculty with no federal funds.
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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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Cost Sharing
Name Description
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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Human Subjects/IRB
Name Description
Assent Form for Adults with Cognitive Impairments Assent form for adults with cognitive impairments. Please NOTE: this is NOT a consent form. This form is for people working with adults who have cognitive impairments such that they cannot sign a consent form themselves, and will need to get consent from that person's caretaker, parent, guardian, etc.
Download File
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.
Download File
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.
Download File
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.
Document Link
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.
Download File
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.
Download File
Debriefing Form - General Form may be used as a handout to debrief participants on any aspect of a research study considered sensitive.
Download File
Determination of Human Subject Research Form Provide information in Kuali 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.
HIPAA Authorization Template Use this form to request access to Health Insurance Portability and Accountability Act (HIPAA) data from individuals.
Download File
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.
Download File
Informed Consent Template - Focus Group - Revised The consent template to be used when research involves focus groups.
Download File
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.
Download File
Informed Consent Template - iDXA Use this template if your research involves iDXA.
Download File
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.
Download File
Informed Consent Template - Magnetic Resonance Imaging (MRI) - Revised Use this template if your study uses Magnetic Resonance Imaging.
Download File
Informed Consent Template - Muscle Biopsy - Revised Use this template if your study includes muscle biopsies.
Download File
Informed Consent Template - Online Survey - Revised Use this template if your study involves an online survey research component.
Download File
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.
Download File
Informed Consent Template - Sensitive Topics - Revised Use this template for research that involves topics which may be considered sensitive.
Download File
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.
Download File
Informed Consent Template - Subject Recruitment Database Use this template if researcher will be asking participants to be part of a subject recruitment database.
Download File
Informed Consent Template - Video Use - Revised Informed Consent form to use for research involving video or audio recordings.
Download File
Informed Consent Template - VO2 Max - Revised Use this template if your study uses V02 Max.
Download File
PAR-Q Screener Script Short script to read before issuing the PAR-Q as a screener.
Download File
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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Physician Clearance Form To provide a rationale for requiring physician clearance for certain participant populations prior to enrolling in a study, and describe all procedures associated with requesting physician clearance.
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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 Amendments Reviewer Checklist for IRB Members to document their review and analysis of Full Board protocols reviewed by the convened IRB. The Reviewer Checklist helps ensure that all required elements of the federal criteria for approval are met.
Download File
Reviewer Checklist for Continuing Review This checklist helps reviewers structure the continuing review of approved protocols and maintain consistency in the process.
Download File
Reviewer Checklist for New Protocols This checklist helps reviewers conduct a review of new protocols and maintain consistency in the process.
Download File
Reviewer Checklist for Renew/Amends Reviewer Checklist for IRB Members to document their review and analysis of Full Board protocols reviewed by the convened IRB. The Reviewer Checklist helps ensure that all required elements of the federal criteria for approval are met.
Download File
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.
Document Link
Proposal Related
Name Description
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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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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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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Sponsor Request Use this form to request a sponsor for use in Kuali. You can also use this form to request a prime sponsor.
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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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Sub-Recipient Commitment Form Distribute this form to participating entities when setting up a subaward/subcontract/sub-recipient agreement with UMass.
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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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Research Ethics
Name Description
Outside Activities - Request for Prior Approval OA form for faculty with no federal funds.
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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).
Download File
Sponsor
Name Description
Sponsor Request Use this form to request a sponsor for use in Kuali. You can also use this form to request a prime sponsor.
Document Link
Subawards
Name Description
Sponsor Request Use this form to request a sponsor for use in Kuali. You can also use this form to request a prime sponsor.
Document Link
Sub-Recipient Commitment 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.
Download File