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SOPs/Protocol-Review/SOP-IRB-001-Protocol-Submission.md
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SOPs/Protocol-Review/SOP-IRB-001-Protocol-Submission.md
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# Standard Operating Procedure: IRB Protocol Submission and Review
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| Document ID | SOP-IRB-001 |
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|-------------|-------------|
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| Title | IRB Protocol Submission and Initial Review Process |
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| Revision | 1.0 |
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| Effective Date | [DATE] |
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| Author | [AUTHOR] |
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| Approved By | [APPROVER] |
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| Department | Institutional Review Board |
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---
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## 1. Purpose
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To establish standardized procedures for the submission, review, and approval of human subjects research protocols in accordance with federal regulations (45 CFR 46, 21 CFR 50/56) and institutional policies.
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## 2. Scope
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This procedure applies to all research involving human subjects requiring IRB review, including:
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- Biomedical research
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- Behavioral research
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- Social science research
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- Educational research
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- FDA-regulated research (drugs, devices, biologics)
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- Exempt, expedited, and full board reviews
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## 3. Responsibilities
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### 3.1 Principal Investigator (PI)
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- Prepare and submit complete protocol application
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- Ensure research team training compliance
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- Respond to IRB stipulations
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- Maintain protocol compliance
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### 3.2 IRB Coordinator
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- Process submissions for completeness
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- Assign review pathway
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- Coordinate reviewer assignments
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- Track submission timelines
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- Communicate decisions
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### 3.3 IRB Chair/Vice Chair
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- Conduct expedited reviews
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- Prepare agenda for full board
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- Sign approval letters
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- Address urgent matters
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### 3.4 IRB Members
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- Review assigned protocols
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- Participate in convened meetings
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- Vote on protocol actions
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- Maintain confidentiality
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## 4. Definitions
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| Term | Definition |
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|------|------------|
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| Common Rule | Federal Policy for the Protection of Human Subjects (45 CFR 46) |
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| Exempt | Research meeting criteria that does not require ongoing IRB oversight |
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| Expedited | Minimal risk research eligible for review outside convened meeting |
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| Full Board | Research requiring review at convened IRB meeting |
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| Minimal Risk | Risk no greater than encountered in daily life |
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## 5. Procedure
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### 5.1 Pre-Submission Requirements
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Before submission, PI must ensure:
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- [ ] All study personnel have completed required training (CITI, GCP)
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- [ ] Training certificates uploaded to protocol file
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- [ ] Conflict of interest disclosures current
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- [ ] Department/division approval obtained (if required)
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- [ ] Funding information available
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- [ ] Study documents prepared (protocol, consent, recruitment materials)
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### 5.2 Protocol Submission
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#### 5.2.1 Required Application Components
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| Document | Required for All | Notes |
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|----------|------------------|-------|
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| Protocol application form | ☐ | Complete all sections |
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| Research protocol/plan | ☐ | Detailed methods |
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| Informed consent form(s) | ☐ | Unless waiver requested |
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| Recruitment materials | If applicable | Flyers, scripts, ads |
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| Data collection instruments | ☐ | Surveys, questionnaires |
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| Investigator brochure | FDA-regulated | Drug/device studies |
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| Grant/funding documents | If externally funded | |
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| Training documentation | ☐ | All personnel |
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| COI disclosures | ☐ | All personnel |
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| Site authorization letters | Multi-site | External sites |
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| Translations | Non-English | Consent, materials |
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#### 5.2.2 Submission Process
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1. Complete application in electronic system
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2. Upload all required documents
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3. Obtain department approval routing
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4. Submit to IRB
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### 5.3 Administrative Review
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IRB staff conducts administrative review within **3 business days**:
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| Check | Action |
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|-------|--------|
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| Application completeness | Return if incomplete |
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| Required documents attached | Request missing items |
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| Training current | Verify certificates |
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| COI disclosures filed | Confirm compliance |
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| Regulatory pathway | Assign review category |
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### 5.4 Review Categories
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#### 5.4.1 Exempt Determination
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Research may qualify for exemption under 45 CFR 46.104 categories:
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1. Educational settings research
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2. Surveys, interviews, observation (with limitations)
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3. Benign behavioral interventions
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4. Secondary research with identifiable data
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5. Federal program evaluation
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6. Taste/food quality studies
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7. Storage or maintenance of specimens/data
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8. Secondary research for regulatory purposes
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**Process:**
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- IRB staff or designated reviewer conducts exemption determination
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- Timeline: 5 business days
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- Outcome: Exempt letter or escalation to expedited/full review
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#### 5.4.2 Expedited Review
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Eligible for expedited if:
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- Minimal risk, AND
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- Falls into expedited categories (45 CFR 46.110)
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**Expedited Categories include:**
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1. Clinical studies of approved products
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2. Collection of blood samples
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3. Prospective collection of specimens (non-invasive)
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4. Data collection through non-invasive procedures
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5. Research on characteristics/behavior
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6. Voice, video, image recording for research
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7. Study of existing data/specimens
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8. Continuing review (specific conditions)
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9. Minor changes to approved research
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**Process:**
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- Assigned to IRB Chair/Vice Chair or experienced member
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- Timeline: 10 business days
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- Outcomes: Approve, require modifications, refer to full board
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#### 5.4.3 Full Board Review
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Required when:
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- Greater than minimal risk, OR
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- Not eligible for expedited categories, OR
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- Involves vulnerable populations with complex issues
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**Process:**
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- Assigned primary reviewer(s)
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- Placed on meeting agenda
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- Quorum required for deliberation
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- Outcomes: Approve, modifications required, table, disapprove
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### 5.5 Review Criteria
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IRB must determine that all of the following are satisfied:
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| Criterion | Requirement |
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|-----------|-------------|
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| Risks minimized | Through sound design, existing procedures when possible |
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| Risks reasonable | In relation to anticipated benefits |
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| Equitable selection | Of subjects, including vulnerable populations |
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| Informed consent | Sought and documented appropriately |
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| Data safety | Adequate provisions for monitoring |
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| Privacy/confidentiality | Adequate protections in place |
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| Vulnerable populations | Additional safeguards when appropriate |
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### 5.6 Informed Consent Evaluation
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#### Required Elements of Consent (45 CFR 46.116)
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- [ ] Statement that study involves research
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- [ ] Explanation of purposes
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- [ ] Expected duration of participation
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- [ ] Description of procedures
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- [ ] Description of reasonably foreseeable risks
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- [ ] Description of benefits
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- [ ] Alternative procedures or treatments
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- [ ] Confidentiality protections
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- [ ] Compensation/treatment for injury (if applicable)
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- [ ] Contact information
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- [ ] Statement that participation is voluntary
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#### Additional Elements (as applicable)
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- [ ] Unforeseeable risks
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- [ ] Circumstances for termination
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- [ ] Additional costs to subject
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- [ ] Consequences of withdrawal
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- [ ] Significant new findings disclosed
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- [ ] Number of subjects
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- [ ] Biospecimen commercial use statement
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- [ ] Whole genome sequencing statement
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### 5.7 IRB Meeting Procedures
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1. **Quorum Requirements**
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- Majority of members
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- At least one non-scientist
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- Scientific expertise relevant to studies reviewed
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2. **Meeting Process**
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- Primary reviewer presents protocol
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- Discussion by members
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- PI may be invited for questions
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- Deliberation (PI excused)
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- Vote by show of hands
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3. **Voting Actions**
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| Action | Definition |
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|--------|------------|
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| Approved | Ready to proceed |
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| Approved with modifications | Minor changes required (verified by Chair) |
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| Tabled | Substantive concerns requiring major revision |
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| Disapproved | Criteria not met, does not meet regulatory requirements |
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### 5.8 Post-Review Communication
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1. **Approval Letter**
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Includes:
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- Approval date
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- Expiration date (if applicable)
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- Approved documents and versions
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- Approval conditions
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- Continuing review requirements
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2. **Modifications Required Letter**
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- Specific changes requested
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- Timeline for response
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- Process for resubmission
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3. **Disapproval Letter**
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- Reasons for disapproval
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- Right to respond/appeal
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### 5.9 Response to Stipulations
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1. PI submits written response addressing each stipulation
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2. Revise documents as requested
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3. Upload revised materials
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4. Chair/reviewer verifies adequacy
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5. Final approval issued when complete
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## 6. Timelines
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| Review Type | Target Timeline |
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|-------------|-----------------|
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| Administrative review | 3 business days |
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| Exempt determination | 5 business days |
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| Expedited review | 10 business days |
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| Full board (to meeting) | Next scheduled meeting |
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| Post-meeting stipulations | 10 business days after response |
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## 7. Documentation
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- FRM-IRB-001 Protocol Submission Form
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- FRM-IRB-002 Informed Consent Template
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- FRM-IRB-003 Reviewer Checklist
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- Meeting minutes
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- Approval/action letters
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- Correspondence log
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## 8. References
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- 45 CFR 46 - Protection of Human Subjects
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- 21 CFR 50 - Protection of Human Subjects (FDA)
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- 21 CFR 56 - Institutional Review Boards (FDA)
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- OHRP Guidance Documents
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- ICH E6 Good Clinical Practice
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---
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## Revision History
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| Rev | Date | Description | Author |
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|-----|------|-------------|--------|
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| 1.0 | [DATE] | Initial release | [AUTHOR] |
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