University of California Davis. Investigator Manual. Revised March 10, 2016

University of California Davis Investigator Manual Revised March 10, 2016

HRP-103 03/10/2016 2 of 41 Table of Contents Scope... 3 What is the purpose of this manual?... 3 What is Human Research?... 3 What is the Human Research Protection Program?... 3 Who is eligible to be a Principal Investigator?... 4 May a student and/or medical resident be a Principal Investigator?... 4 What training do my staff and I need to conduct Human Research?... 4 What financial interests do my staff and I need to disclose to conduct Human Research?... 5 How do I submit new Human Research to the IRB?... 6 How do I write an Investigator Protocol?... 7 How do I create a consent document?... 7 What are the different regulatory classifications that research activities may fall under?... 8 What are the decisions the IRB can make when reviewing proposed research?... 8 How does the IRB decide whether to approve Human Research?... 9 What will happen after IRB review?... 9 What are my obligations after IRB approval?... 10 How do I document consent?... 11 How do I submit a modification?... 12 How do I submit continuing review?... 12 How do I close out a study?... 13 How long do I keep records?... 13 What if I need to use an unapproved drug, biologic, or device and there is no time for IRB review?... 14 What other internal reviews are also involved in the protection of human subject research?... 14 How do I get additional information and answers to questions?... 15 Appendix A Prompt Reporting Requirements... 17 Appendix B-1 Additional Requirements for DHHS-Regulated Research... 19 Appendix B-2 Additional Requirements for FDA-Regulated Research... 20 Appendix B-3 Additional Requirements for Clinical Trials (ICH-GCP)... 27 Appendix B-4 Additional Requirements for Department of Defense (DOD) research... 35 Appendix B-5 Additional Requirements for Department of Energy (DOE) Research... 36 Appendix B-6 Additional Requirements for Department of Justice (DOJ) Research... 37 Additional Requirements for DOJ Research conducted in the Federal Bureau of Prisons... 37 Additional Requirements for DOJ Research Funded by the National Institute of Justice... 39 Appendix B-7 Additional Requirements for Department of Education (ED) Research... 40 Appendix B-8 Additional Requirements for Environmental Protection Agency (EPA) Research... 41

Scope Investigator Manual HRP-103 03/10/2016 3 of 41 Throughout this document Institution refers to University of California Davis. What is the purpose of this manual? This document INVESTIGATOR MANUAL (HRP-103) is designed to guide you through policies and procedures related to the conduct of Human Research that are specific to this Institution. This document discusses the mechanics of working with the IRB and Human Research Protection Program and is not meant to be a repeat of required training. General information regarding Human Research protections and relevant federal regulations and guidance is incorporated into the required human protections training. For additional information see: What training does my staff and I need in order to conduct Human Research? What is Human Research? The HUMAN RESEARCH PROTECTION PROGRAM PLAN (HRP-101) defines the activities that this Institution considers to be Human Research. An algorithm for determining whether an activity is Human Research can be found in the WORKSHEET: HUMAN RESEARCH DETERMINATION (HRP-310), located in the IRB Policies & Procedures section of the IRB Web site. Use this document for guidance as to whether an activity meets either the DHHS or FDA definition of Human Research, keeping in mind that the IRB makes the ultimate determination in questionable cases as to whether an activity constitutes Human Research subject to IRB oversight. You are responsible not to conduct Human Research without prior IRB review and approval (or an Institutional review and approval of exempt Human Research). If you have questions about whether an activity is Human Research, contact the IRB Office who will provide you with a determination. If you wish to have a written determination, provide a written request to the IRB Office. What is the Human Research Protection Program? The document HUMAN RESEARCH PROTECTION PROGRAM PLAN (HRP-101) describes this Institution s overall plan to protect subjects in Human Research. The mission of the Human Research Protection Program. The ethical principles that the Institution follows governing the conduct of Human Research. The applicable laws that govern Human Research. When the Institution becomes engaged in Human Research and when someone is acting as an agent of the Institution conducting Human Research. The types of Human Research that may not be conducted. The roles and responsibilities of individuals within the Institution.

HRP-103 03/10/2016 4 of 41 Who is eligible to be a Principal Investigator? This Institution's faculty members with paid appointments of 50% or more of full-time may serve as the principal investigator on a research project involving human subjects. In certain situations, students may also assume roles as principal investigators as long as they have a faculty sponsor who fulfills the principal investigator eligibility criteria and who will serve as a faculty advisor on the study. May a student and/or medical resident be a Principal Investigator? This Institution allows students and/or medical residents to act as Principal Investigators in human subject research. They are required to obtain a Faculty Advisor to oversee, guide, and sign off on their research. The Faculty Advisor is required to be listed as part of the research personnel (staff) of the study and to complete a human subject research online training course (see section "What training do my staff and I need to conduct Human Research?). If the research is to be funded, the institution's policies require that an exception to policy for Principal Investigator eligibility to be requested. For further information please utilize the following links: Students: http://research. ucdavis.edu/wp-content/uploads/form-105-a-request-for- Exception-to-Policy-on-Eligibility-to-Submit-Proposals.pdf Medical Residents: http://www.ucdmc.ucdavis.edu/medresearch/medsp/pi.html May researchers, who are not faculty, students, or employees of UC Davis, conduct human subject research at UC Davis? If you are not a faculty member, student, or employee of UC Davis who wishes to conduct human subject research either at UC Davis or with UC Davis faculty, students, or employees, you must contact the UC Davis IRB Administration in writing before engaging in any research activities on the UC Davis campuses or targeting UC Davis faculty, students or employees. May research personnel, who are not faculty, students, or employees of UC Davis, conduct human subject research at UC Davis? Investigators and researchers who wish to include research personnel who are not a faculty member, student, or employee of UC Davis must contact the UC Davis IRB Administration in writing before allowing the research personnel to engage in human subject research activities. What training do my staff and I need to conduct Human Research? This section describes the training requirements imposed by the IRB. You may have additional training imposed by other federal, state, or University policies. Any additional requirements will

HRP-103 03/10/2016 5 of 41 be directed by the funding agency, Sponsored Programs, Legal Affairs, Compliance, Contracts, your department, and/or the IRB Administration. Investigators and staff conducting research involving more than minimal risk to subjects must complete the Collaborative Institutional Training Initiative (CITI) human subjects online training program. Investigators and staff conducting research involving no more than minimal risk to subjects must complete either the online CITI program or the National Institutes of Health (NIH) Protection Human Research Participants Course (PHRP). Investigators and staff conducting clinical trials 1 are required to take GCP training, either through CITI or by providing a copy of their ACRP or SoCRA certification. The CITI site can be accessed at http://www.citiprogram.org/. The NIH PHRP site can be accessed at http://phrp.nihtraining.com/users/login.php. Training is valid for a three-year period, after which time the training must be repeated. All members of the research team involved in the research must complete training. Members of the research team who have not completed human research protections training may not take part in aspects of the research that involve human subjects. What financial interests do my staff and I need to disclose to conduct Human Research? You must follow the institution s policies on financial interests in research described the UC Davis Policy and Procedure Manual (PPM) under Individual Conflicts of Interest Involving Research (230-05) and/or Public Health Service Regulations on Objectivity in Research (230-07), and also in the University of California s policy under Disclosure of Financial Interests & Management of Conflicts of Interest, Public Health Service Research Awards (UC-RG-12-0133). All individuals involved in the design, conduct, or reporting of research are required to disclose whether they have any financial interests related to the research as listed in the Financial Interest Declaration sections of INITIAL REVIEW APPLICATION and FORM: CONTINUING REVIEW PROGRESS REPORT (HRP-212). This notification is required: On submission of an initial review. At least annually as part of continuing review. Within 30 days of discovering or acquiring (e.g., through purchase, marriage, or inheritance) a new financial interest. Researchers with positive disclosures in the Initial Review Application and/or form HRP-212 are directed to the Conflict of Interest Committee Website and forms for submission to the Conflict 1 Clinical Trial (NIH Definition): A research study in which one or more human subjects are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health- related biomedical or behavioral outcomes.

HRP-103 03/10/2016 6 of 41 of Interest Committee: http://research.ucdavis.edu/resources/forms/#forms- FinancialConflictsofInterest. How do I submit new Human Research to the IRB? The UC Davis IRB utilizes an electronic database called IRBNet, which provides a suite of tools accessible via the internet, electronic protocol management, online submission and many other important research oversight features to the research community. IRBNet is hosted at a secure, enterprise-class data center that supports and meets the strict requirements of federal regulations 2. Complete the INITIAL REVIEW APPLICATION, attach all requested supplements, including FORM: ADMINISTRATIVE APPROVAL (HRP-226), if applicable, check department policy in regards to electronic signatures for department chair, have the Initial Review Application electronically signed by the Principal Investigator, and submit the completed packet to the IRB Administration. FORM HRP-226, signed by the Department Chair (and Dean, when the investigator is under the School of Nursing), is used as documentation evidencing the Principal Investigator s qualifications. The Department Chair, Dean (if applicable, and Faculty Advisor (if applicable) may sign FORM HRP-226 physically or electronically in IRBNet. The Department Chair certifies the following: The Principal Investigator is qualified by education, training and experience to personally conduct and/or supervise the research described in the protocol. The Principal Investigator has completed all applicable institutional credentialing processes to conduct this research. The Principal Investigator has sufficient resources to carry out this research as proposed. The protocol is scientifically valid and employs research procedures which are consistent with sound research design. The Principal Investigator will conduct the protocol in accordance with requirements in the INVESTIGATOR MANUAL (HRP-103) listed in the section, What are my obligations after IRB approval? Maintain electronic copies of all information submitted to the IRB in case revisions are required. Before submitting the research for initial review, you must: Determine whether any member of the research staff has a financial interest related to the research. If yes, determination from Conflict of Interest Committee must be submitted to the IRB Administration prior to IRB approval. Obtain the agreement of each research staff to his/her role in the research. There are four Institutional Review Boards (IRBs) at UC Davis: Biomedical Committee A, Biomedical Committee B, Social and Behavioral Committee C, and Fast Track Committee D. For additional information, including the schedule of meeting dates, please visit http://research.ucdavis.edu/policiescompliance/irb-admin/researchers/about-the-committees/ 2 21 CFR Part 11, Electronic Records; Electronic Signatures Scope and Application

HRP-103 03/10/2016 7 of 41 How do I write an Investigator Protocol? Use the INITIAL REVIEW APPLICATION, within IRBNet, as a starting point for drafting a new Investigator Protocol, and reference the instructions in the IRBNET USER MANUAL: INITIAL REVIEW APPLICATION for the information the IRB looks for when reviewing research. Here are some key points to remember when developing an Investigator Protocol: The italicized bullet points in the IRBNET USER MANUAL: INITIAL REVIEW APPLICATION serve as guidance to investigators when developing an Investigator Protocol for submission to the IRB. If you believe your activity may not be Human Research, contact the IRB Administration prior to developing your Investigator Protocol. Note that, depending on the nature of your research, certain sections of the application may not be applicable to your Investigator Protocol. The INITIAL REVIEW APPLICATION is a dynamic SmartForm that auto generates the questions based on the previous questions answered. You may not involve any individuals of the following populations as subjects in your research unless you indicate this in your application. As the inclusion of subjects in these populations has regulatory implications. o Adults who lack the capacity to provide legally effective consent o Individuals who are not yet adults (infants, children, teenagers) o Pregnant women o Prisoners If you are conducting community-based participatory research, you may contact the IRB Administration for information about: o Research studies using a community-based participatory research design o Use of community advisory boards o Use of participant advocates o Partnerships with community-based Institutions How do I create a consent document? Use the TEMPLATE CONSENT DOCUMENT (HRP-502) to create a consent document. Note that all long form consent documents and all summaries for short form consent documents must contain all of the required and all additional appropriate elements of informed consent disclosure. Review the Long Form of Consent Documentation section in the IRB s WORKSHEET: CRITERIA FOR APPROVAL AND ADDITIONAL CONSIDERATIONS (HRP-314), to ensure that these elements are addressed. When using the short form of consent documentation the appropriate signature block from TEMPLATE CONSENT DOCUMENT (HRP-502) should be used on the short form. We require that you date the revisions of your consent documents to ensure that you use the most recent version approved by the IRB.

HRP-103 03/10/2016 8 of 41 What are the different regulatory classifications that research activities may fall under? Submitted activities may fall under one of the following four regulatory classifications: Not Human Research : Activities must meet the Institutional definition of Human Research to fall under IRB oversight. Activities that do not meet this definition of are not subject to IRB oversight or review. Review the IRB Office s WORKSHEET: HUMAN RESEARCH (HRP-310) for reference. Contact the IRB Office in cases where it is unclear whether an activity is Human Research. Exempt: Certain categories of Human Research may be exempt from regulation but require IRB review. It is the responsibility of the Institution, not the investigator, to determine whether Human Research is exempt from IRB review. Review the IRB Administration s WORKSHEET: EXEMPTION DETERMINATION (HRP-312) for reference on the categories of research that may be exempt. Review Using the Expedited Procedure: Certain categories of non-exempt Human Research may qualify for review using the expedited procedure, meaning that the project may be approved by a single designated IRB reviewer, rather than the convened board. Review the IRB Administration s WORKSHEET: ELIGIBILITY FOR REVIEW USING THE EXPEDITED PROCEDURE (HRP-313) for reference on the categories of research that may be reviewed using the expedited procedure. Review by the Convened IRB: Non-Exempt Human Research that does not qualify for review using the expedited procedure must be reviewed by the convened IRB. What are the decisions the IRB can make when reviewing proposed research? The IRB may approve research, require modifications to the research to secure approval, table research, or disapprove research: Approval: Made when all criteria for approval are met. See How does the IRB decide whether to approve Human Research? below. Modifications Required to Secure Approval: Made when IRB members require specific modifications to the research before approval can be finalized. Deferred: Made when the IRB determines that the board is unable to approve research and the IRB suggests modifications the might make the research approvable. When making this motion, the IRB describes its reasons for this decision, describes modifications that might make the research approvable, and gives the investigator an opportunity to respond to the IRB in person or in writing. Tabled: Made when the IRB cannot approve the research at a meeting for reasons unrelated to the research, such as loss of quorum. When taking this action, the IRB automatically schedules the research for review at the next meeting.

HRP-103 03/10/2016 9 of 41 Disapproval: Made when the IRB determines that it is unable to approve research and the IRB cannot describe modifications the might make the research approvable. When making this motion, the IRB describes its reasons for this decision and gives the investigator an opportunity to respond to the IRB in person or in writing. How does the IRB decide whether to approve Human Research? The criteria for IRB approval can be found in the WORKSHEET: EXEMPTION DETERMINATION (HRP-312) for exempt Human Research and the WORKSHEET: CRITERIA FOR APPROVAL AND ADDITIONAL CONSIDERATIONS (HRP-314) for nonexempt Human Research. The latter worksheet references other checklists that might be relevant. All checklists and worksheets can be found on the IRB Website. These checklists are used for initial review, continuing review, and review of modifications to previously approved Human Research. You are encouraged to use the checklists to write your Investigator Protocol in a way that addresses the criteria for approval. What will happen after IRB review? The IRB will provide you with a written decision indicating that the IRB has approved the Human Research, requires modifications to secure approval, or has disapproved the Human Research. If the IRB has approved the Human Research: The Human Research may commence once all other Institutional approvals have been met. IRB approval is usually good for a limited period of time which is noted in the approval letter. If the IRB requires modifications to secure approval and you accept the modifications: Make the requested modifications and submit them to the IRB (SOP: INCOMING ITEMS DIRECTED TO THE IRB [HRP-020]). If all requested modifications are made, the IRB will issue a final approval per SOP: POST-REVIEW (HRP-052). Research cannot commence until this final approval is received. If you do not accept the modifications, write up your response and submit it to the IRB. The response will be placed on the next available agenda for review by a convened IRB (SOP: PRE-REVIEW [HRP-021] and SOP: IRB MEETING CONDUCT [HRP-041]). If the IRB defers the Human Research: The IRB will provide a statement of the reasons for deferral and suggestions to make the study approvable, and give you an opportunity to respond in writing. Address the suggestions and submit the response to the IRB (SOP: INCOMING ITEMS DIRECTED TO THE IRB [HRP-020]). The response will be placed on the next available agenda for review by a convened IRB (SOP: PRE-REVIEW [HRP-021] and SOP: IRB MEETING CONDUCT [HRP-041]). In most cases, if the IRB s reasons for the deferral are addressed in the modifications, the Human Research can be approved (SOP: POST-REVIEW [HRP-052]). If the IRB disapproves the Human Research: The IRB will provide a statement of the reasons for disapproval and give you an opportunity to respond in writing.

HRP-103 03/10/2016 10 of 41 In all cases, you have the right to address your concerns to the IRB directly at an IRB meeting. What are my obligations after IRB approval? 1) Do not start Human Research activities until you have the final IRB approval letter. 2) Do not start Human Research activities until you have obtained all other required institutional approvals, including approvals of departments or divisions that require approval prior to commencing research that involves their resources. For instance, when an investigational drug or biologic is involved, you are required to defer responsibility for accounting, storage, dispensing, etc. to the Investigational Drug Services (IDS) Pharmacy, located at the UC Davis Medical Center. 3) Ensure that there are adequate resources to carry out the research safely. This includes, but is not limited to, sufficient investigator time, appropriately qualified research team members, equipment, and space. 4) Ensure that Research Staff are qualified (e.g., including but not limited to appropriate training, education, expertise, credentials, protocol requirements and, when relevant, privileges) to perform procedures and duties assigned to them during the study. 5) Update the IRB office with any changes to the list of study personnel when required to submit the continuing review report. 6) Personally conduct or supervise the Human Research. a) Conduct the Human Research in accordance with the relevant current protocol as approved by the IRB. b) When required by the IRB ensure that consent or permission is obtained in accordance with the relevant current protocol as approved by the IRB. c) Do not modify the Human Research without prior IRB review and approval unless necessary to eliminate apparent immediate hazards to subjects. d) Protect the rights, safety, and welfare of subjects involved in the research. 7) Submit to the IRB: a) Proposed modifications as described in this manual. (See How do I submit a modification? ) b) A continuing review application as requested in the approval letter. (See How do I submit continuing review? c) A continuing review application when the Human Research is closed. (See How Do I Close Out a Study? ) 8) Report to the IRB using FORM: REPORTABLE NEW INFORMATION (HRP-214), any of the information items in Appendix A within five to ten business days as outlined in Appendix A. a) The IRB will review FORM HRP-214 to determine if any of the information items meet the definitions of serious noncompliance, continuing noncompliance or an unanticipated problem involving risks to subjects or others (UPIRTSO), as listed in SOP: DEFINITIONS (HRP-001). b) Examples of UPIRTSOs include: i) Internal adverse events that are unexpected, involve new or increased risks, and are related to the research.

HRP-103 03/10/2016 11 of 41 ii) External adverse events that are unanticipated problems involving risks to participants or others. iii) Changes made to the research without prior IRB approval in order to eliminate apparent immediate harm. iv) Other unanticipated information that is related to the research and when participants or others might be at increased risk of harm. 9) Submit an updated disclosure of financial interests within thirty days of discovering or acquiring (e.g., through purchase, marriage, or inheritance) a new financial interest. 10) Do not accept or provide payments to professionals in exchange for referrals of potential subjects ( finder s fees. ) 11) Do not accept payments designed to accelerate recruitment that were tied to the rate or timing of enrollment ( bonus payments. ) 12) See additional requirements of various federal agencies in Appendix B. These represent additional requirements and do not override the baseline requirements of this section. How do I document consent? Review the IRB Administration's "SOP: WRITTEN DOCUMENTATION OF CONSENT (HRP-091)". Use the signature block approved by the IRB. Complete all items in the signature block, including dates and applicable checklists. The following are the requirements for long form consent documents: The subject or representative signs and dates the consent document. The individual obtaining consent signs and dates the consent document. Whenever required by the IRB or sponsor, the subject s or representative s signature is to be witnessed by an individual who signs and dates the consent document. Whenever the IRB or the sponsor require a witness to the oral presentation, the witness signs and dates the consent document. A copy of the signed and dated consent document is to be provided to the subject. If the subject is a patient of the University of California Davis Health System, a copy of the signed and dated consent form must be placed in the subject s medical record. The following are the requirements for short form consent documents (refer to WORKSHEET: SHORT FORM OF CONSENT DOCUMENTATION (HRP-317) for additional information on compliant use of the short form method of consent documentation): The subject or representative signs and dates the short form consent document and the summary. The individual obtaining consent signs and dates the short form consent document and the summary. The witness to the oral presentation signs and dates the short form consent document and the summary. Copies of the signed and dated consent document and summary are provided to the subject or representative. If the subject is a patient of the University of California Davis Health System, a copy of the signed and dated consent form must be placed in the subject s medical record.

HRP-103 03/10/2016 12 of 41 How do I submit a modification? Complete the FORM: MODIFICATION (HRP-213), attach all requested supplements, have the form signed, electronically via IRBNet, by the individuals listed in the form, and submit the documents to the IRB Administration via IRBNet. Maintain electronic copies of all information submitted to the IRB in case revisions are required. Please note that research must continue to be conducted without inclusion of the modification until IRB approval is received. Updates to the list of study personnel should be submitted with the continuing review report. Modifications are categorized into minor changes and significant changes. A minor modification is defined as a proposed change in research-related activities that does not significantly affect an assessment of the risks and benefits of the study and does not substantially change the specific aims or design of the study. Minor modifications may be reviewed using the expedited IRB procedure (WORKSHEET: ELIGIBILITY FOR REVIEW USING THE EXPEDITED PROCEDURE [HRP-313]). A significant modification is defined as a proposed change in research-related activities that significantly affects an assessment of the risks and benefits of the study or substantially changes the specific aims or design of the study. Significant modifications require review by the full IRB Committee (WORKSHEET: CRITERIA FOR APPROVAL AND ADDITIONAL CONSIDERATIONS [HRP-314]). How do I submit continuing review? Complete the FORM: CONTINUING REVIEW PROGRESS REPORT (HRP-212), attach all requested supplements, have the formed signed, electronically via IRBNet, by the individuals listed in the form, and provide the requested number of copies to the IRB Administration via IRBNet. Maintain electronic copies of all information submitted to the IRB in case revisions are required. Before submitting the research for continuing review, you must: Determine whether any member of the research staff has a financial interest related to the research. If yes, determination from Conflict of Interest Committee must be submitted to the IRB Administration prior to IRB approval. Obtain the verbal or written agreement of each member of the research staff to his/her role in the research. If the continuing review involves modifications to previously approved research, submit those modifications using the FORM: MODIFICATION (HRP-213)" with the continuing review submission. If changes to study personnel have occurred since the last continuing review report was submitted, update the electronic Initial Review Application Form with these changes or submit a revised FORM HRP 215 Research Personnel List Template with the continuing review report. If the continuing review application is not received by the administrative due date requested in the approval letter, you will be required to develop and implement a suitable corrective and preventive action plan (CAPA).

HRP-103 03/10/2016 13 of 41 If the continuing review application is not received by the protocol expiration date in the approval letter you will be required to develop and implement a suitable CAPA and restricted from submitting new Human Research until the completed application has been received If the approval of Human Research expires all Human Research procedures related to the protocol under review must cease, including recruitment, advertisement, screening, enrollment, consent, interventions, interactions, and collection or analysis of private identifiable information. Continuing Human Research procedures during a lapse is a violation of the Institution s policy and in some cases federal regulations. If current subjects will be harmed by stopping Human Research procedures that are available outside the Human Research context, provide these on a clinical basis as needed to protect current subjects. If current subjects will be harmed by stopping Human Research procedures that are not available outside the Human Research context, immediately contact the IRB chair and provide a coded list of the currently enrolled subjects and describe in writing why they will be harmed by stopping Human Research procedures. How do I close out a study? Complete the FORM: CONTINUING REVIEW PROGRESS REPORT (HRP-212), attach all requested supplements, have the formed signed, electronically via IRBNet, by the individuals listed in the form, and provide the requested number of copies to the IRB Administration via IRBNet. Maintain electronic copies of all information submitted to the IRB in case revisions are required. If the continuing review application for closing out a Human Research study is not received by the date requested in the approval letter, you will be restricted from submitting new Human Research until the completed application is received. How long do I keep records? Maintain your Human Research records, including signed and dated consent documents for at least three years after completion of the research. If your research involved or pertained children, after completion of the research maintain your Human Research records, including signed and dated consent documents, for at least 7 years after the child reaches the age of maturity (18 years of age in California). If your research involved or pertained to in vitro or pregnant women, maintain your Human Research records, including signed and dated consent documents for at least 25 years after completion of the research. Maintain signed and dated HIPAA authorizations and consent documents that include HIPAA authorizations for at least six years after completion of the research. If your Human Research is sponsored, consult with the Office of Sponsored Programs determine how long you must retain records. Contact the sponsor before disposing of Human Research records. For further information on required retention and disposition of administrative records relating to research, please visit University of California, Office of the President website "Research Policy Analysis and Coordination".

HRP-103 03/10/2016 14 of 41 What if I need to use an unapproved drug, biologic, or device and there is no time for IRB review? Contact the IRB Administration or IRB chair immediately to discuss the situation. If there is no time to make this contact, see the WORKSHEET: EMERGENCY USE (HRP-322) for the regulatory criteria allowing such a use and make sure these are followed. Use the TEMPLATE EMERGENCY USE CONSENT DOCUMENT (HRP-506) to prepare your consent document. You will need to submit a report of the use to the IRB within five days of the use and for drugs and biologics, submit an IRB application for initial review within 30 days. If you fail to submit the report within five days or the IRB application for initial review within 30 days, you will be restricted from submitting new Human Research until the report and IRB application for initial review have been received. Emergency use of an unapproved drug or biologic in a life-threatening situation without prior IRB review is research as defined by FDA, the individual getting the test article is a subject as defined by FDA, and therefore is governed by FDA regulations for IRB review and informed consent. Emergency use of an unapproved device without prior IRB review is not research as defined by FDA and the individual getting the test article is not a subject as defined by FDA. However, FDA guidance recommends following similar rules as for emergency use of an unapproved drug or biologic. Individuals getting an unapproved drug, biologic, or device without prior IRB review cannot be considered a subject as defined by DHHS and their results cannot be included in prospective research as that term is defined by DHHS. You should also review the University of California Davis Innovative Use Policy (2516) What other internal reviews are also involved in the protection of human subject research? Institutional Biosafety Committee (IBC) The IBC reviews research using biological agents, recombinant DNA research for compliance and conformance with NIH Guidelines, recommends level of medical surveillance of personnel associated with the research project after review by the campus Occupational Health Physician, and recommends modifications, curtailment, or termination of any projects when it is in the best interest of the health and safety of the campus community. If the IRB identifies studies not approved by the IBC, the IRB review process will be postponed pending review and approval by the IBC. Investigators may also contact the Committee directly for review requirements. The IRB will not approve a study requiring IBC review without that Committee s approval. Conflict of Interest Committee (COIC)- Any actual or perceived conflict of interest as defined by institutional policy, consistent with applicable federal and state regulations is required to be reported to and reviewed by the Conflict of Interest Committee (COIC). The COIC will inform the IRB when investigators conducting human research have significant financial interests that constitute a financial conflict of interest. The IRB has the final authority and may grant final approval of research studies with a disclosed conflict of interest, provided that the IRB has taken

HRP-103 03/10/2016 15 of 41 appropriate steps to eliminate or manage the conflict, consistent with the Conflict of Interest Committee determination (see SOP: FINANCIAL CONFLICTS OF INTEREST [HRP-055]). Should the IRB or the Conflict of Interest Committee require changes in the research study to mitigate a conflict; the Principal Investigator will be required to submit the revised documents for IRB review and approval. Cancer Center Scientific Review Committee (CCSRC) The CCSRC is charged with the review and monitoring of protocols involving cancer patients and/or their data. The Committee provides a centralized mechanism for prospective evaluation of scientific merit, resource allocation, and clinical cancer research monitoring. The application requires that Principal Investigators contact the Cancer Center Scientific Review Committee for the review and approval of their research study, prior to submission of the protocol for IRB review and approval. The IRB will not approve a protocol involving cancer patients and/or their data without the approval of the CCSRC. Radiation Use Committee (RUC) The RUC is responsible for the surveillance of all uses of radioactive materials and ionizing radiation (including diagnostic x-rays/fluoroscopy/ DEXA) in research involving human participants. Principal Investigators are required to identify, on INITIAL REVIEW APPLICATION, all proposed radiation use. The application requires that Principal Investigators contact the Radiation Use Committee for the review and approval of their study, prior to IRB review and approval. The RUC may require amendments to the design of the study, restrictions, or specific wording in the informed consent document, to ensure conformance with the University s Radioactive Material License and state and federal regulations. The IRB will not approve a research study involving radiation without the prior approval/exemption of the Radiation Use Committee. Stem Cell Research Oversight Committee (SCROC)- The SCROC 1) provides oversight of all issues related to derivation and use of human adult and embryonic stem cell lines; 2) reviews and approves the scientific merit of research protocols; 3) reviews compliance of all human adult and embryonic stem cell research with all relevant regulations and guidelines; and 4) facilitates education of investigators involved in human adult and embryonic stem cell research. Principal Investigators are required to identify, on INITIAL REVIEW APPLICATION, all human adult and embryonic stem cell studies. The application requires that Principal Investigators contact the Stem Cell Research Oversight Committee for the review and approval of their research study. How do I get additional information and answers to questions? This document and the policies and procedures for the Human Research Protection Program are available on the IRB Web Site at http://research.ucdavis.edu/policiescompliance/irbadmin/policies-procedures-regulations/irb-sops/ If you have any questions or concerns, about the Human Research Protection Program, contact the IRB Administration at: 2921 Stockton Blvd Suite 1400, Room 1429

HRP-103 03/10/2016 16 of 41 Sacramento, CA 95817 Email: hs-irbadmin@ucdavis.edu Phone: (916) 703-9151 Fax: (916) 703-9160 If you have questions, concerns, complaints, allegations of undue influence, allegations or findings of non-compliance, or input regarding the Human Research Protection Program that cannot be addressed by contact the IRB Administration, follow the directions in the HUMAN RESEARCH PROTECTION PROGRAM PLAN (HRP-101) under Reporting and Management of Concerns.

HRP-103 03/10/2016 17 of 41 Appendix A Prompt Reporting Requirements Report the following information items to the IRB within 5 business days using this form: If information contained within a report has previously been submitted to the IRB Administration, do not submit a second time unless the updated report includes new information that would affect or revise the IRB s previous determination. Information that does not fall under any of the categories does not require reporting to the IRB. 1) Information that indicates a new or increased risk, or a new safety issue, for example: a) New information (e.g., an interim analysis, safety monitoring report, publication, sponsor report, or investigator. finding) indicating an increase in the frequency or magnitude of a previously known risk, or reveals a new risk. b) Protocol violation that harmed subjects or others or that indicates subjects or others might be at increased risk. c) Subject complaint that indicates subjects or others might be at increased risk of harm or at risk of a new harm. d) An investigator brochure, package insert, or device labeling is revised to indicate an increase in the frequency or magnitude of a previously known risk, or describe a new risk. e) Withdrawal, restriction, or modification of a marketed approval of a drug, device, or biologic used in a protocol. f) Changes significantly affecting the conduct of the clinical trial or increasing the risk to participants. 2) Serious harm experienced by a subject or other individual, which in the opinion of the investigator is unexpected and probably related (>50% likely; "Don't know" = <50%) to the research procedures. A harm is "serious" when it meets any of the following criteria; 1.) results in death; 2.) is life-threatening (places the subject at immediate risk of death from the event as it occurred); 3.) results in inpatient hospitalization or prolongation of existing hospitalization; 4.) results in a persistent or significant disability/incapacity; 5.) results in a congenital anomaly/birth defect; 6.) based upon appropriate medical/psychological judgment, may jeopardize the subject s health and may require medical, counseling, or surgical intervention to prevent one of the other outcomes listed in this definition; or 7.) results in criminal or civil liability or damaging of the subject s financial standing, employability, or reputation. A harm is unexpected when its specificity or severity are inconsistent with risk information previously reviewed and approved by the IRB in terms of nature, severity, frequency, and characteristics of the study population. A harm is probably related to the research procedures if in the opinion of the investigator, the research procedures more likely than not caused the harm. 3) Change to the protocol done without prior IRB review to eliminate an apparent immediate hazard to a subject. Report the following within 10 business days: 4) Non-compliance with the federal regulations governing human research or with the requirements or determinations of the IRB, or an allegation of such non-compliance. 5) Failure to follow the protocol due to the action or inaction of the investigator or research staff. 6) Breach of confidentiality (inappropriate disclosure of or access to confidential information). 7) Complaint of a subject that cannot be resolved by the research team. 8) Premature suspension or termination by the sponsor, investigator, or institution. 9) Incarceration of a subject in a study not approved by the IRB to involve prisoners. 10) Inquiry by a federal agency and any reports (e.g., FDA Form 483).

HRP-103 03/10/2016 18 of 41 11) Ancillary approvals (e.g. CoC, SCRO) that do not result in a protocol revision; written reports by study monitors and auditors that include reportable events that have not yet been reported [1] ; Data Safety Reports that include a recommendation to terminate or modify a study. 12) Unanticipated adverse device effect (any serious adverse effect on health or safety or any life-threatening problem or death caused by, or associated with, a device, if that effect, problem, or death was not previously identified in nature, severity, or degree of incidence in the investigational plan or application (including a supplementary plan or application), or any other unanticipated serious problem associated with a device that relates to the rights, safety, or welfare of subjects). 13) Other: information or situations that do not meet any of the above criteria. [1] If the monitoring report includes information that falls under category 1(b), 4, 5, or 6 please include a preventive action plan, indicate whether the event was previously reported or include a statement that you will submit separate or updated RNIs with preventive action plans for the new reportable events included on the report.

HRP-103 03/10/2016 19 of 41 Appendix B-1 Additional Requirements for DHHS-Regulated Research 3 1. When a subject decides to withdraw from a clinical trial, the investigator conducting the clinical trial should ask the subject to clarify whether the subject wishes to withdraw from all components of the trial or only from the primary interventional component of the trial. If the latter, research activities involving other components of the clinical trial, such as follow-up data collection activities, for which the subject previously gave consent may continue. The investigator should explain to the subject who wishes to withdraw the importance of obtaining follow-up safety data about the subject. 2. Investigators are allowed to retain and analyze already collected data relating to any subject who chooses to withdraw from a research study or whose participation is terminated by an investigator without regard to the subject s consent, provided such analysis falls within the scope of the analysis described in the IRB-approved protocol. This is the case even if that data includes identifiable private information about the subject. 3. For research not subject to regulation and review by FDA, investigators, in consultation with the funding agency, can choose to honor a research subject s request that the investigator destroy the subject s data or that the investigator exclude the subject s data from any analysis. 4. When seeking the informed consent of subjects, investigators should explain whether already collected data about the subjects will be retained and analyzed even if the subjects choose to withdraw from the research. 3 Guidance on Withdrawal of Subjects from: Data Retention and Other Related Issues http://www.hhs.gov/ohrp/policy/subjectwithdrawal.html

HRP-103 03/10/2016 20 of 41 Appendix B-2 Additional Requirements for FDA-Regulated Research 1. When a subject withdraws from a study: 4 a. The data (including specimens) collected on the subject to the point of withdrawal remains part of the study database and may not be removed. b. An investigator may ask a subject who is withdrawing whether the subject wishes to provide continued follow-up and further data collection subsequent to their withdrawal from the interventional portion of the study. Under this circumstance, the discussion with the subject would distinguish between study-related interventions and continued follow-up of associated clinical outcome information, such as medical course or laboratory results obtained through non-invasive chart review, and address the maintenance of privacy and confidentiality of the subject s information. c. If a subject withdraws from the interventional portion of the study, but agrees to continued follow-up of associated clinical outcome information as described in the previous bullet, the investigator must obtain the subject s informed consent for this limited participation in the study (assuming such a situation was not described in the original informed consent form). IRB approval of informed consent documents is required. d. If a subject withdraws from the interventional portion of a study and does not consent to continued follow-up of associated clinical outcome information, the investigator must not access for purposes related to the study the subject s medical record or other confidential records requiring the subject s consent. e. An investigator may review study data related to the subject collected prior to the subject s withdrawal from the study, and may consult public records, such as those establishing survival status. 2. For FDA-regulated research involving investigational drugs: a. Investigators must abide by FDA restrictions on promotion of investigational drugs: 5 i. An investigator, or any person acting on behalf of an investigator, must not represent in a promotional context that an investigational new drug is safe or effective for the purposes for which it is under investigation or otherwise promote the drug. ii. This provision is not intended to restrict the full exchange of scientific information concerning the drug, including dissemination of scientific findings in scientific or lay media. Rather, its intent is to restrict promotional claims of safety or effectiveness of the drug for a use for 4 Data Retention When Subjects Withdraw from FDA-Regulated Clinical Trials http://www.fda.gov/downloads/regulatoryinformation/guidances/ucm126489.pdf 5 Promotion of investigational drugs http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=312.7

HRP-103 03/10/2016 21 of 41 which it is under investigation and to preclude commercialization of the drug before it is approved for commercial distribution. iii. An investigator must not commercially distribute or test market an investigational new drug. b. Follow FDA requirements for general responsibilities of investigators 6 i. An investigator is responsible for ensuring that an investigation is conducted according to the signed investigator statement, the investigational plan, and applicable regulations; for protecting the rights, safety, and welfare of subjects under the investigator's care; and for the control of drugs under investigation. ii. An investigator must, in accordance with the provisions of 21 CFR 50, obtain the informed consent of each human subject to whom the drug is administered, except as provided in 21 CFR 50.23 or 50.24 of this chapter. iii. Additional specific responsibilities of clinical investigators are set forth in this part and in 21 CFR 50 and 21 CFR 56. c. Follow FDA requirements for control of the investigational drug 7 i. An investigator must administer the drug only to subjects under the investigator's personal supervision or under the supervision of a subinvestigator responsible to the investigator. ii. The investigator must not supply the investigational drug to any person not authorized under this part to receive it. d. Follow FDA requirements for investigator recordkeeping and record retention 8 i. Disposition of drug: 1. An investigator is required to maintain adequate records of the receipt, storage, and disposition of the drug, including dates, quantity, and use by subjects. 2. If the investigation is terminated, suspended, discontinued, or completed, the investigator must return the unused supplies of the drug to the sponsor, or otherwise provide for disposition of the unused supplies of the drug under 21 CFR 312.59. ii. Case histories. 1. An investigator is required to prepare and maintain adequate and accurate case histories that record all observations and other data pertinent to the investigation on each individual administered the investigational drug or employed as a control in the investigation. 2. Case histories include the case report forms and supporting data including, for example, signed and dated consent forms and 6 General responsibilities of investigators http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=312.60 7 Control of the investigational drug http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=312.61 8 Investigator recordkeeping and record retention http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=312.62