Fillable Printable VA Form 10-1223
Fillable Printable VA Form 10-1223
VA Form 10-1223
Page 1 of 1
VA FORM
DEC 2005
10-1223
RECOMMENDATION:
COMMITTEE FINDINGS:
1. The information given in the Informed Consent under the Description of Research
by Investigator is complete, accurate, and understandable to a research subject or a
surrogate who possesses standard reading and comprehension skills.
2. The informed consent is obtained by the principal investigator or a trained and
supervised designate under suitable circumstances.
3. Every effort has been made to decrease risk to subject(s)?
4. The potential research benefits justify the risk to subject(s)?
5. If subject is incompetent and surrogate consent is obtained, have all of the
following conditions been met; a) the research can’t be done on competent subjects;
b) there is no risk to the subject, or if risk exists the direct benefit to subject is
substantially greater; c) if an incompetent subject resists, he will not have to
participate; d) if there exists any question about the subject’s competency, the basis
for decision on competency has been fully described.
6. If the subject is paid the payment is reasonable and commensurate with the
subject’s contribution.
7. Members of minority groups and women have been included in the study
population whenever possible and scientifically desirable.
REPORT OF SUBCOMMITTEE ON HUMAN STUDIES
Principal Investigator
Project/Program Title
VAMC
Review Date:
8. Comments: (Indicate if Expedited Review)
NO
YES
SIGNATURE OF CHAIRMAN (Sign in ink)
DATE
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
DISAPPROVE/REVISEAPPROVE
