Please complete and fax this form to 301-320-0978 (or email to hii@hii.org)
Submit resume or brief biographical sketch highlighting relevant qualification & experience.

Award for Excellence in Human Research Protection recognizes demonstrated excellence and innovation in human research protection. There are 3 Award categories:

• Best Practice — given to a research institution, an unit, or an individual that has the best way, one of the best ways, or a proven way to achieve, or to contribute toward achieving, the protection that is the specified purpose of the practice
• Innovation — given to an individual (or a team) who has introduced an innovation in or a novel approach to the protection of human research subjects
• Life-time Achievement — given to an individual who has made significant contributions to the protection of human subjects of research over a continuous period of at least 20 yearsest practice that has demonstrated benefit - given to a research institution, unit (for example, Institutional Review Board), or individual

Health Improvement Institute invites participation on volunteer panels to judge applications for an Award. The deadline for receipt of Award application is the last Monday of September. Judges must complete their evaluations by the end of October.

Please complete and fax to 301-320-0978 - page 1 of ____ Click for PDF format

Name:	_____________________________________________________________________________
Organization:	_____________________________________________________________________________
Position/Title:	_____________________________________________________________________________
Address:	_____________________________________________________________________________
	_____________________________________________________________________________
Telephone:	__________________________ Fax: ______________________________________________
Email:	_____________________________________________________________________________

• How would you prefer to receive correspondence (check one): fax email mail packet
• I would like to be a member of the Judges Credentialing Committee (JCC): Yes No
• I would like to judge the following Award categories (check all that apply):
  Best Practice Innovation Life-time Achievement

Please complete below and sign at end.

1. Please check the one category that is most applicable:

1.1 Present organization:
Accrediting organization	Health professional association (e.g., AMA, ANA)
Consumer advocacy organization	Independent consultant/Individual
Drug/device manufacturer	Law firm
Government/regulatory agency	Research performer - center/institute/university
Healthcare facility (e.g. hospital)	Research sponsor/funder
Health plan/insurer	Voluntary health association (e.g., Red Cross)
Health trade association (e.g., AHA, BIO,  PHARMA)	Other, please specify below:
	________________________________________
1.2 Present role in research enterprise:
Administrator (of research institution/center)	Proposal/study reviewer - ethics
Consumer/research participant advocate	Proposal/study reviewer - science
Consultant to IRB/HRP program	Public relations/communications professional
Educator/trainer	Regulator (government)
HRP compliance officer/auditor	Social scientist (who studies the enterprise)
HRP professional/IRB staff	Study administrator/coordinator
HRP QI/CQI committee member	Study monitor/auditor/evaluator
Investigator/researcher	Study staff
IRB/ethics committee member	Surveyor (accrediting organization)
Journal reviewer (ethics/science)	Other, please specify below:
	________________________________________
2. Research experience	5. Human research protection experience -
2.1 For how many years have you been actively	In the past 5 years, in which of the following
involved in the human research enterprise	ways have you protected human subjects of
(excluding years that you were not fully involved)?	research?
_____	Check all that apply
	Conflict of interest committee
2.2 How many of the last 5 years have you been	Consumer/participant advocate
actively involved in the human research	Consultant to IRB/HRP program
enterprise in a role relevant to the	HRP compliance officer/auditor
protection of people who participate in	HRP program oversight
research studies? _____	HRP QI/CQI committee
	Investigator/researcher
2.3 What type of human research have you done,	IRB/ ethics committee - member
and for how many years (excluding years	IRB/HRP program - staff
that you were not fully involved)?	Journal reviewer (ethics/science)
Check all that apply	Proposal/study reviewer - ethics
None	Proposal/study reviewer - science
Behavioral research, surveys, etc;	Regulator (government)
_____years	Scientific integrity committee
Clinical (biomedical) research; _____ years	Study administrator/coordinator
Other, specify below; _____ years	Study monitor/auditor/evaluator
_____________________________________	Study staff
	Surveyor (accrediting organization)
3. Certifications - Which of the following types of	Other, specify: __________________________
certification (given by a recognized professional
body) do you hold? Check all that apply	6. Adverse professional events - In the last
IRB professional	5 years, have you been, or are you currently,
Research administrator	involved with any event that could call
Other relevant certification, specify	into question your suitability to be a
_____________________________________	judge (e.g., adverse action regarding quality
	of care, professional conduct, research
4. Human research protection (HRP) training	integrity, etc)?
4.1 In the past 5 years, which of the following	Yes; explain below      No
types of formal training (e.g., regarding
federal regulations) have you completed	7. Comments - including any other relevant
successfully? Check all that apply	qualifications or experience, explanations of
Investigator	adverse professional events, etc.
Institutional official
IRB member
IRB staff/support
Research staff (including, e.g., CRO)
Surveyor (for HRP accreditation)
Training of trainers
Other, specify: __________________________
4.2 Have you received formal training in the last
5 years or are you knowledgeable about
current federal regulations pertaining to:
Protecting human subjects of research?
Training in last 5 yrs Knowledgeable No
Assuring the integrity of research?
Training in last 5 yrs Knowledgeable No