Registration Form for Collaborative Studies between UMASS Amherst and Baystate Medical Center

This form is used for researchers from the University of Massachusetts Amherst (UMASS) who are collaborating in human subject research with researchers at the Baystate Medical Center (Baystate). To determine your eligibility, including information on biosafety and conflict of interest clearance, please refer to IRB Guidance - IRB Review of Collaborative Research with UMass Amherst and Baystate before submitting this form.

Date

Year

Month

Day

UMASS Researcher Name:

UMASS Researcher Department:

UMASS Researcher Email Address:

List Additional UMASS Co-Investigators:

Baystate Researcher Name:

Baystate Researcher Department:

Project Title:

Brief Project Description, including how human subjects are involved:

List Funding Agency and OGCA# (if applicable):

If funded, indicate here if the application for IRB approval differs from the grant and how it differs:

State if UMASS is the prime grant recipient and list all subcontracts involved, if applicable:

Do any researchers have conflict of interest with sponsoring agency?

Indicate if you will be using human tissue/body fluids. If so, specify where specimens will be housed. All researchers and laboratories must be certified through Environmental Health & Safety (EH&S):

Leave this field blank

Registration Form for Collaborative Studies between UMASS Amherst and Baystate Medical Center

Research Administration and Compliance

Research and Engagement

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