IRB Study #:	Click once to insert IRB Study # here

Study Title:	Click once to insert title here

1. Who translated the document?
Select one	Name of Person or Organization Translating the Document
A well-qualified individual	Click once to insert the name of the translator here
A reputable translation service	**STOP**do not use this form. Submit Certificate of Translation

2. For Translations performed by an individual, a second qualified individual needs to complete the verification statement below:

Statement from the second qualified individual verifying the translation: By signing the form, you certify that you have verified the accuracy and completeness of the translation of the [Click once to insert name of document here] from English to the local language of [click once to insert language]. You certify that the translation matches the IRB approved English version which has an IRB approval stamp dated: [click once to insert IRB approval date of English version]. The method/strategy used to verify that the translation accurately and completely represents the English version was [click once to insert method/strategy of verifying the translation]. Signature section for person verifying this translation:
Verifier’s Name
Verifier’s contact information
Verifier’s Signature & Date	Date

3. Certification by the Principal Investigator
The PI is ultimately responsible for the translations. By submitting this request, the PI certifies that: to the best of his/her knowledge, the translation of the document identified above is accurate, complete, and ready to be used with prospective research subjects. the PI has information about the credentials of the agency or individuals who provided the translation and verification and which enabled the PI to conclude they were qualified and the translation is trustworthy. This information can be made available to the IRB upon request.