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Resources: For Accreditation - Evaluation Instrument

Evaluation Instrument for Accreditation

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Latest Update: April 5, 2024

Table of Contents



ELEMENT III.2.B.: Researchers maintain appropriate oversight of each research study, as well as research staff and trainees, and appropriately delegate research responsibilities and functions.
Researchers are ultimately responsible for the conduct of research. Although researchers may delegate certain responsibilities and functions of the research, they must maintain oversight and retain ultimate responsibility for the conduct of those to whom they delegate responsibility.
When researchers delegate responsibilities or functions, they should ensure that research staff are trained and able to perform the function and assume the responsibility for the delegated function.

Regulatory and guidance references

Required written materials

  1. Essential requirements:
    1. Policies and procedures indicate that if the principal researcher or the local site researcher does not personally obtain consent, the researcher must formally and prospectively designate to another research team member in writing the protocol or the application for IRB approval the responsibility for obtaining consent, whether a waiver of documentation of the consent process has been approved by the IRB.  
    2. If the researcher contracts with a firm to obtain consent, the firm must have its own IRB.
    3. Students and other trainees (including residents and fellows), including VA employees, from schools with an academic affiliation agreement consistent with current VHA policy, may serve as members of research teams, but not serve as principal researcher within a VA facility, or use data, or human biological specimens that have been collected within VA for clinical, administrative, or research purposes.  
    4. A researcher sufficiently experienced in the area of the trainee’s research interest must serve as principal researcher or co-principal researcher and is responsible for oversight of the research and the trainee.  
  2. When following DOJ requirements:
    1. Policies and procedures indicate that for research conducted within the Bureau of Prisons, the researcher must assume responsibility for actions of any person engaged to participate in the research project as an associate, assistant, or subcontractor to the researcher.
  3. When following the ICH-GCP (E6) guideline: 
    1. Policies and procedures describe that the researcher maintains a list of appropriately qualified persons to whom they have delegated significant clinical trial-related duties.
  4. When following VA requirements:
    1. If the principal researcher or local site researcher does not personally obtain informed consent, the researcher must delegate this responsibility in writing (e.g., by use of a delegation letter) to research staff sufficiently knowledgeable about the protocol and related concerns to answer questions from prospective participants, and about the ethical basis of the informed consent process and protocol.
    2. If the researcher contracts with a firm (e.g., a survey research firm) to obtain consent from participants, collect private individually identifiable information from human participants, or be involved in activities that would institutionally engage the firm in human participants research, the firm must have its own IRB oversight of the activity.
      1. In addition, the Privacy Officer (PO) must determine that there is appropriate authority to allow the disclosure of individual names and other information to the contracted firm.

Common types of materials that may be used to meet the element

  • Researcher manual


  • Researchers are involved in the conduct of the research, including recruitment and obtaining consent, and maintain oversight of recruitment, consent, and protocol procedures.
  • Researchers hire qualified staff.
  • Research Staff indicate that the researcher delegates responsibility to them commensurate with their training and qualifications.
  • Researchers are available to research staff when needed.

Proceed To: ELEMENT III.2.C.