The goal of the QI Program is to continue the Partner's tradition of excellence, to conduct all research involving human subjects according to the highest standards, recognizing that doing so makes us a premier site for clinical research.

Please note, not all sections of the Self-Assessment Checklist may apply to your study. You have the option of completing each section individually or going through the entire checklist. Once you have completed the Self-Assessment Checklist, you can save the document to your local drive and/or print out a hard copy for your records. Members of the QI staff will be available to assist you and to answer any questions you may have.

CHECKLIST CONTENT:

Regulatory Documentation

IRB Documentation

Subject Recruitment Procedures

Subject Selection Criteria

Informed Consent Process

Adverse Event Reporting

Protocol Violations, Deviations, Exceptions

Drug / Device Dispensing Accountability

Data Collection & Source Documents

Record Keeping

Genetic Research

Regulatory Documentation

Regulatory documentation includes the essential documents that individually and collectively permit the evaluation of the conduct of the trial and the quality of the data produced. The QI Program recommends a separate study file or binder in which these documents can be kept. Recommendations as to content and format can also be found by viewing the QI Program's Virtual Regulatory Binder.

Depending on the type of study you are conducting and the study sponsor, different regulatory documents are required. All studies conducted at Partners should comply with Good Clinical Practice (GCP) guidelines and Partners Human Research Committee (PHRC) Institutional Policies. To ensure that your study site is compliant with GCP standards and PHRC policies, complete Section I for all studies.

SECTION I

	YES	NO	N A
Is documentation of Federal Wide Assurance (FWA) number on file? If no, documentation can be found at: http://healthcare.partners.org/phsirb/assure.htm
Are all applicable signed agreements/contracts between parties on file? (e.g. between PI and sponsor; between PI and CRO)
Is the most recent version of the IRB approved protocol on file?
Are all previous versions of the IRB approved protocol on file?
Are copies of most recently approved sample case report forms (CRF) on file?
Are there CVs/biosketches of PI, Co-Is, and all study staff on file?
Are CVs updated within the past two years?
Are CVs signed and dated?
Is there a subject enrollment log?
Is study site monitored?
Is there a monitoring log?
Are copies of site visit (external) monitoring reports on file?
If yes, do monitoring reports include Site Initiation report/visit documentation?
If yes, do monitoring reports include study close-out report/visit documentation?
Are all relevant communications (e.g. meeting notes, letters and emails) with study sponsor on file?
Is there a staff signature log?
Does the study signature log reflect current staff working on the study?
Are all staff working on the study IRB approved?
Does the staff signature log (or other documentation) capture delegation of responsibility?
Are lab tests required?
If yes, is a copy of normal lab values on file?
If yes, is lab certification on file, (e.g. CLIA)?
If yes, is the lab director's CV on file?
Is there a Data Safety Monitoring Board (DSMB) for this study?
Has the DSMB operated in accordance with the IRB approved Protocol?
Are all DSMB reports or indication of DSMB review and recommendations on file?
Have all DSMB reports been submitted to the IRB?
Is this an NIH funded study?
If yes, are the NIH grant and annual progress reports on file?

Regulatory Documentation: Investigational Products

Investigators conducting studies under INDs or IDEs are required to maintain additional regulatory documentation. The extent of this additional regulatory documentation depends on whether the investigator is considered a Clinical Investigator or a Sponsor-Investigator for the study. If your investigator is a ‘Clinical Investigator' conducting an FDA regulated trial, complete Section II.

If your investigator is a ‘Sponsor-Investigator' complete Sections II and III to ensure compliance with FDA regulations.

Section II: For Clinical Investigators and Sponsor Investigators

	YES	NO	NA
The study is being conducted under an IND (drug/biologic) IDE (device)
For IND studies, is there a signed FDA 1572 on file?
For IDE studies, is an Investigator Statement on file?
Is a Financial Disclosure form or a memo disclosing any financial conflicts/interests on file for each investigator listed on the 1572 or in the Investigator Statement?
Is valid licensure on file for each investigator/staff member listed on the 1572 or in the Investigator Statement?
Are all correspondences to and from the sponsor on file?
Is there a copy of the Investigator Brochure or Device Manual on file?
If the product is already marketed, is there a package insert/product information on file?

Section III: For Sponsor Investigators Only

	YES	NO	NA
Is the PI a sponsor-investigator (i.e. IND/IDE holder)?
If yes, is the following on file:
Original IND/IDE application to the FDA
FDA letter of no objection
Amendments to the IND/IDE
Annual reports to the IND/IDE
Safety reports
General correspondence with the FDA
For IND studies, is there a FDA 1571 on file to accompany all of the above FDA correspondence?
For IND studies, note who is listed as the monitor in section 14 of the FDA form 1571. Is this person monitoring the study for subject safety and protocol adherence according to the protocol's data and safety monitoring plan?

IRB DOCUMENTATION

In addition to initial review and approval, all subsequent actions by an investigator/study site must be approved by the IRB prior to implementation. This includes protocol amendments, consent form revisions, and study staff changes. Adverse events and protocol deviations must also be reported according to PHRC guidelines. All correspondence with the HRC must be maintained on file.

	YES	NO	NA
Is the initial application to the IRB on file?
Is all correspondence (signed/dated applications and/or electronic submission signature sheets, responses, approvals) to the IRB on file:
Number of Continuing Reviews (CR)? Are all continuing review submissions on file?
Was each CR submitted on time? (45 days prior to expiration)?
Was there any lapsed period(s) between expiration date and CR approval date?
If yes, was any subject enrolled during the lapse period?
If yes, was a protocol violation submitted to the IRB?
Were any study-related activities conducted during the lapse period?
If yes, is there documentation on file that these activities were approved by an IRB Chair?
Number of Amendments? Are all amendment submissions on file?
Were the protocol summary, detailed protocol and/or consent form updated to reflect all approved amendments?
Are all adverse event submissions on file?
Are all protocol deviation submissions on file?
If this is a multi-site study, were copies of safety reports (i.e. unexpected and related or possibly related events) received from the sponsor submitted to the IRB?
Are all notifications of IRB deferral/requires modification/ disapproval on file?
Are all PI responses to these IRB notifications on file?
Are all IRB notifications of approval on file?
Are all IRB submissions and PI responses on file copies of the signed and dated originals?
If no, are electronic submission signature sheets on file?
Are copies of all e-mail correspondence with the IRB on file?

SUBJECT RECRUITMENT PROCEDURES

Subjects can be recruited to a study in a variety of ways, including for example, bulletins, newspaper, T.V. and radio ads. The IRB must review and approve all methods used to recruit all subjects. Partners policies for recruitment, including advertising and remuneration can be found at: http://healthcare.partners.org/phsirb/guidance.htm .

	YES	NO	NA
Are recruitment methods described in the IRB approved protocol?
Have all recruitment materials been approved by the IRB?
Are all approved recruitment materials (original and all revisions) on file?
Were changes made to recruitment materials since the last continuing review?
If yes, were changes IRB approved prior to implementation?
Is a pre-screening telephone interview conducted?
If yes, is the pre-screen form and phone script IRB approved?

SUBJECT SELECTION CRITERIA

Study subjects are screened for involvement in a study based on IRB approved inclusion/exclusion criteria. Partners Investigator's Responsibilities requires investigators to develop an eligibility checklist with specific objective criteria to document that each subject has met the selection criteria. In addition, the PI is responsible for ensuring that source documentation supporting eligibility is available in the subject's medical record and/or study file.

	YES	NO	NA
Is there an eligibility checklist containing inclusion/exclusion criteria for all enrolled subjects?
Does the eligibility criteria checklist for each subject include dated signature/initials of the person obtaining the information?
For any enrolled subjects that did not meet eligibility criteria, was a request for a protocol exception submitted to the IRB prior to enrollment?
For IRB approved protocol exceptions, was the sponsor (if applicable) made aware of the exception to enroll the subject?
For subjects who did not meet eligibility (e.g. screen-failures), was identifiable information destroyed or authorization obtained to keep subject information?

INFORMED CONSENT PROCESS

During the course of the study, changes to the IRB approved protocol may necessitate a change to the consent form(s). These changes can include new safety information, revised study procedures or eligibility criteria, or text clarifications. All consent form revisions must be IRB-approved. IRB approval is documented by use of a stamp, containing a valid date and expiration date. A consent form that does not contain this approval stamp, or a consent form used after the expiration date, is considered invalid. It is essential that the study site use only the most recently approved version of the consent form to consent subjects. Whenever a new approved consent form is generated, and stamped with a valid date, it replaces all previously approved versions. New versions are also generated (with or without change) at the time of continuing review.

Choose a random sample of consent forms that have been completed by enrolled subjects. Review each consent form and complete the following section to ensure proper documentation of informed consent.

How many consent forms are being utilized for this study (e.g. youth assent form, parental consent, healthy volunteer, health condition-specific)?
	YES	NO	NA
Are original copies of all IRB-approved consent forms on file?
Was informed consent obtained from each subject prior to the start of any study procedure(s), including screening procedures to determine eligibility?
Was a valid IRB-approved consent form used to consent each subject? Invalid consent form includes consent form without IRB approval stamp; expired consent form; incorrect study population.
If no, was a protocol violation report submitted to the IRB?
Is the consent form on file for each subject the original signed and dated version (not a photocopy)?
Are all pages of the consent form on file for each subject?
Is subject identification (name, subject # or code, written or imprinted with hospital card) on all pages of the consent form?
Are all yes/no or similar options on the consent form completed/initialed for all subjects?
Are all consent forms free of any handwritten changes/corrections?
Did each subject sign his/her own consent form? (Exceptions: IRB-approved surrogate or parental consent)
Did each subject date his/her own consent form?
Did the study representative sign each consent form?
Did the study representative date each consent form?
Did the subject and study representative enter the same date on the consent form?
Were all study representatives who signed the consent forms approved by the IRB to obtain informed consent?
If no, was a violation report submitted to the IRB?
Did each subject receive a copy of the signed and dated consent form?
Is subject's receipt of a copy of the signed and dated consent form documented? How: (e.g. progress note, CRF, enrollment log)
Was a copy of the subject's signed and dated consent form filed with Medical Records?
If no, is there an IRB approved exceptions (e.g., sensitive research, such as drug or alcohol use, genetic studies)
Is the number of subjects who signed a consent form (i.e., enrolled) less than or equal to the target enrollment goal approved by the IRB?

Adverse Event (AE) reporting

An adverse event is defined as any untoward or unfavorable medical occurrence in a human subject, including any abnormal sign (for example, abnormal exam or laboratory finding), symptom, or disease, temporarily associated with the subject's participation in the research, whether or not considered related to the subject's participation in the research. These events are typically associated with physical or psychological, rather than social or economic, harm. Internal AEs are those experienced by subjects at sites that rely on the PHRC for IRB review. External AEs, reported to the PI in the form of safety reports, are those occurring at sites that do not rely on the PHRC for IRB review.

The PI is responsible for assessing adverse events according to the following criteria:

• Serious vs. non-serious
• Expected (in terms of the nature, severity, or frequency) vs. unexpected
• Related (or possibly related) vs. unrelated

The outcome of this assessment will determine reporting requirements to the PHRC. PHRC reporting requirements may differ from those of the Sponsor and/or Federal agencies; in such cases, the individual requirements of each group must be met. Partners policy for reporting adverse events can be found at: http://healthcare.partners.org/phsirb/adverse_events.htm

For internal Adverse Events	YES	NO	NA
Have all serious, unexpected, and related (or possibly related) internal adverse events been reported to the PHRC within 10 working days/14 calendar days after the investigator was notified of the event?
Have all non-serious, unexpected, and related (or possibly related) adverse events been reported to the PHRC within 20 working days/30 calendar days after the investigator was notified of the event?
Were sponsors and/or Federal agencies (such as the FDA if the investigator is the IND or IDE holder) notified of AEs according to their requirements?
Is the study being monitored by a sponsor, coordinating or statistical center, DSMB/DSC?
If yes, was a copy of the most recent monitoring group report submitted to the PHRC?
If yes, was a summary of any unexpected and related adverse events since the last continuing review submitted to the PHRC with the continuing review applications?
Is the investigator responsible for monitoring his/her own investigator-initiated research?
If yes, was a summary of all adverse events submitted to the PHRC with the continuing review applications? An AE Reporting log is available at: http://phsResearchIntranet.partners.org/PHS_HumanResearchQI/AETrackingLog.xls

For External Adverse Events	YES	NO	NA
Were all serious, unexpected, and related (or possibly related) adverse events reported to the PHRC within 10 working days/14 calendar days of the date the investigator first became aware of the events? Exception: If the study is no longer being conducted at a Partners site, only those adverse events that may impact the health, welfare, or safety of subjects who were enrolled at Partners site(s) need to be reported to the PHRC.
Were all non-serious, unexpected, and related (or possibly related) adverse events reported to the PHRC within 20 working days/30 calendar days after the investigator was notified of the event?

PROTOCOL VIOLATIONS, DEVIATIONS and exceptions

Investigators are responsible for conducting research in accordance with the IRB approved protocol. During the conduct of the study, any deviation from the protocol, planned or otherwise, must be reviewed and approved by the IRB prior to implementation. Any temporary protocol deviation that is approved by the IRB prior to its initiation is called an exception. Protocol exceptions that are not IRB approved prior to initiation are called violations. Protocol violations can be either minor or major, subject safety, data integrity or affecting the subject's willingness to participate in the study. Partners' policy for reporting protocol deviations, exceptions, and violations can be found at: http://healthcare.partners.org/phsirb/prodevex.htm.

Review a sample of subject files to ensure adherence to the IRB approved protocol. For chosen files, check to see, for example, that all required/applicable laboratory tests, imaging, follow-up visits, and questionnaires have been completed in accordance with the IRB approved protocol.

	YES	NO	NA
Have there been any deviations from the IRB approved protocol?
If yes, were deviations from the IRB approved protocol approved in the form of protocol exceptions prior to implementation?
If not approved as exceptions, how many of these are major violations? How many are minor violations?      __
Were the major violations submitted to the IRB as required (i.e. upon discovery and prior to continuing review)?
Were (or will) the minor violations be submitted to the IRB at the time of continuing review?
Have there been any sponsor-approved protocol exceptions?
If yes, have they been reported to the IRB?
Do any of the deviations require modification of the current protocol to avoid reoccurrence?
· If yes, has an amendment been submitted to the IRB ?

DRUG/DEVICE DISPENSING ACCOUNTABILITY

The investigator is responsible for investigational product accountability. When possible, the investigator may delegate accountability to an appropriate individual under the investigator's supervision. It is common that an investigator will assign investigational drug or biologic accountability to a Research Pharmacy. Devices are typically maintained at the trial site. Product accountability information can be filed with other Regulatory documentation or in a separate file/binder. The following section should be completed in order to ensure that investigational product accountability is being maintained.

Who is responsible for receipt of study drug/biologic/device ? Study Site Research Pharmacy Other
	YES	NO	NA
If the site is responsible, are there shipping/receiving receipts on site?
Who is responsible for drug/biologic/device storage? Study Site Research Pharmacy or Investigational Drug Services Other
If site is responsible, the following measures are in place (check all that apply) to ensure that the product is stored in appropriate conditions. Temperature log Locked secure area Limited staff access
Who is responsible for drug/biologic/device dispensing to the subject? Investigator Research Nurse Coordinator Other
	YES	NO		NA
Is there documentation of drug/biologic/device use for each subject (e.g. drug accountability log, study file notation)?
Is there a sample label from investigational product container on file?
Is there documentation for the return or destruction of drug/biologic/device?
Have there been any drug/biologic/device-related errors to date?
If yes, did any of these errors result in harm to subjects?
If no, have these errors been reported to the IRB as unanticipated problems?

DATA COLLECTION & SOURCE DOCUMENTS

Investigators are required to maintain adequate, complete, and accurate records of all observations and data pertinent to each study subject. A case report form (CRF) or site-developed data collection sheet is a form on which all study data are recorded for each subject. All data entries on CRFs or data collection sheets should be verified by existing source data.

Source documents are the first places where all information, records of clinical findings, observations, or other study activity is recorded. Examples of source documents include medical records, x-rays laboratory results, pharmacy records, operative reports, and diagnostic test results.

All data collection, including applicable source documents, should be signed and dated by the individual recording the information. Additional guidance on data collection and source documentation (which are consistent with GCP guidelines) can be found at:

http://www.partners.org/phsqi/InvestigatorInformationPage.htm

	YES	NO	NA
Is data collection complete/accurate for each subject (e.g. no blank fields/missing data)?
Is source documentation available to support data entry for each subject?
Does the source documentation/CRF for each subject include dated signature/initials of the person obtaining the information for each subject?
Are changes/cross-outs, additional comments (if any) in subject files routinely initialed and dated?
For any changes/cross-outs being made, is the original entry still legible? (e.g. use of white-out or pencil erased entries is not acceptable)

RECORD KEEPING

Partners Investigator's Responsibilities require investigators to keep good records. Review your study binder/records to ensure fulfillment of this responsibility. At a minimum, subject files should include a copy of the signed and dated consent form and eligibility criteria checklist.

	YES	NO
Do you keep a binder/folder for regulatory documents?
Do you keep a binder/folder for IRB correspondence?
Do you keep a study file for each subject?
Has there been any unintentional disclosure of confidential information in this study?

GENETIC RESEARCH

All PHRC recruitment and informed consent policies apply in genetic research. There are a number of additional factors that investigators need to consider when preparing consent forms, developing recruitment plans, and writing the protocol for genetic research. These special considerations address both the investigator's responsibilities to safeguard subjects' privacy and confidentiality and subjects' rights to participate in decisions about the research use of their genetic information. Guidance documents and consent form templates can be found at: http://healthcare.partners.org/phsirb/genetic.htm