IRB Application form - Fisher College

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Fisher College
Institutional Review Board (IRB)
Application for Research Approval
The Fisher College IRB reviews all requests to conduct research involving human subjects. It is the
investigator’s responsibility to give complete information regarding procedures and the informed
consent process. After completing the application, the IRB will notify the applicant, in writing, of its
decision.
Before submitting the application, please read the following scenarios and make a check next to the
selection that best applies to your project:
You are performing research using human subjects - IRB review and approval needed
You are requesting a course reduction to do research with human subjects – IRB and
Administrative review and approval needed **
You are requesting a course reduction for research that does not involve human subjects – IRB
review (no approval needed) and Administrative approval needed **
You are requesting to use Fisher resources or information for a research or a project (e.g.
dissertation or master’s research, graduate course project, etc.) with human subjects – IRB
review and approval and Administrative review and approval **
You are requesting to use Fisher resources or information for research or a project (e.g.
dissertation or master’s research, graduate course project, etc.) without human subjects – IRB
review and Administrative review and approval **
**If your project requires Administrative Approval, it will be submitted to the appropriate
Administration representative after IRB review.
REQUIREMENTS:
The Principal Investigator must supply the following:
____ A completed application
____ A copy of all questionnaires and surveys
____ Approval from Program Director (if appropriate)
Please print or type responses.
1. Project Title: _________________________________________________________
Principal Investigator: _____________________________________________________
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Department: _____________________________________________________________
Phone: _________________________ Email: __________________________________
Faculty Sponsor (if student) ________________________________________________
Faculty Phone: __________________ Email: __________________________________
Is this a class project ____Yes ____No
Project/Thesis ____Yes ____ No
Projected Start Date: ______________ Projected Completion Date: _________________
Is a proposal for external funding being submitted ____ Yes ____ No
2. Project Abstract
Provide a brief summary of the proposed research, purpose of the study, variables of the study, and
value of the study.
3. Methodology
Provide a description of your research methodology. Include the measures, where and how you plan to
collect data, and over what time period. Identify all personnel who will participate in this research and
outline their qualifications.
4. Participants
Are participants members of a population who do not
have the ability to provide informed consent
Will the participants be younger than 18 years old
Will the participants be Fisher College students
Will participants receive compensation for participation
(If “yes”, please describe)
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________
How will participants be selected or recruited
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________
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5. Risks
Describe any and all known or anticipated risks to the participants (psychological or physical).
6. Benefits
Describe the anticipated benefits to the participants.
7. Informed Consent
Attach a copy of all informed consent documents.
8. Confidentiality and Anonymity
Describe how participants’ privacy will be maintained and how confidentiality will be guaranteed.
9. Responsibilities of the Principal Investigator
Any additions or changes must be submitted to the IRB for written approval prior to these changes being
implemented.
Any problems connected with the use of human subjects once the project has begun must be brought to
the attention of the IRB.
Informed Consent documents must be kept for a period of 3 years following the completion of the
project.
10. Signatures
I certify to the best of my knowledge the information presented is an accurate reflection of the proposed
research project.
A. _____________________________ _____________________
Principal Investigator
Date
B. _____________________________ _____________________
Faculty Sponsor (only for students)
Date
Faculty sponsor confirms the accuracy of the application and accepts responsibility for the conduct of
the research.
C. ____________________________ ______________________
Program Director (only for students)
Date
October 21, 2009