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  Home > Academics > Psychology > Application for Review of Human Subjects Research
 
 
 
Application for Review of Human Subjects Research
Submitted to the
Jamestown College Institutional Review Board
 
 
Title of Project:
 
Is the Project externally funded? () Yes   () No
If yes, complete the following: () Private   () State   () Federal
 
Agency:    Grant No:
 
Type of Review Requested: (Refer to JC IRB Information Packet for an explanation of the types of review.)
() Exempt   () Expedited (include reasons below)   () Full Board
 
 
 
Principal Investigator(s): I acknowledge that this represents an accurate and complete description of my research. (NOTE: If there are more than two PIs, provide information on a separate sheet.)
 
Name of Primary PI:
 
Date:
 
Department:
 
PI's Address:
 
PI's Phone:
 
E-Mail:
 
Name of Co-PI:
 
Date:
 
Department:
 
Co-PI's Address:
 
Co-PI's Phone:
 
E-Mail:
 
 
Adviser (complete if PI is a student): I agree to provide the proper surveillance of this project to ensure that the rights and welfare of the human subjects are properly protected.
 
Name of Advisor:
 
Date:
 
Department:
 
Advisor's Address:
 
Advisor's Phone:
 
E-Mail:
 
 
1. Describe the background and the purpose of the research.
 
 
2. (a) Describe the participants of this study:
 
1) Describe the sampling procedures:
      
 
2) Describe the sampling population:
      
 
3) Number of participants expected to participate:
      
 
4) How long will the participants be involved:
      
 
5) Describe any follow-up procedures planned:
      
 
6) Describe the calendar time frame for gathering the data using human participants:
      
 
7) Describe any anticipated risks:
      
 
Note: Include a copy of the script or other means to be used to solicit participants.
 
      (b) Are any participants under 18 years of age?
 
() Yes   () No
 
If yes, you must comply with special regulations for using children as participants. Please refer to the IRB Guide.
 
3. Describe each proposed condition, intervention, or manipulation of human participants or their environments. Include a copy of any questionnaires, tests, or other written instruments, instructions, scripts, etc., to be used within the study.
 
 
4. Will the participants encounter the possibility of stress or psychological, social, physical, or legal risks that are greater than those encountered in ordinary daily life or during the performance of routine physical or psychological examinations or tests?
 
() Yes   () No
 
If Yes, please explain:
 
 
5. Will medical clearance be necessary for participants to participate because of tissue or blood sampling, or administration of substances such as food or drugs, or physical exercise conditioning?
 
() Yes   () No
 
If Yes, please explain how clearance will be obtained:
 
 
6. Will the participants be deceived or misled in any way?
 
() Yes   () No
 
If Yes, please explain:
 
 
7. Will there be a request for information that participants might consider to be personal or sensitive?
 
() Yes   () No
 
If Yes, please explain:
 
 
8. Will participants be presented with materials that might be considered to be offensive, threatening, or degrading?
 
() Yes   () No
 
If Yes, please explain, including measures planned for intervention if problems occur.
 
 
9. Will any inducements be offered to the participants for their participation?
 
() Yes   () No
 
If Yes, please explain:
 
 
10. Will a written consent form (and assent form for minors) be used?
 
() Yes   () No
 
If Yes, please include the form(s).
 
If No, a waiver of written consent must be obtained from the IRB, Explain in detail why a written consent form will not be used and how voluntary participation will be obtained. Include any related material, such as a copy of a public notice, script, etc., that you will use to inform participants of all the elements that are required in a written consent.
 
11. Will any aspect of the data be made a part of any record that can be identified with the subject?
 
() Yes   () No
 
If Yes, please explain:
 
 
12. Describe the steps you are taking to protect the confidentiality of the participants, and how you are going to advise participants of these protections in the consent process.
 
 
13. Will the participant's participation in a specific experiment or study made a part of any record available to a supervisor, teacher, or employer?
 
() Yes   () No
 
If Yes, please describe:
 
 
14. Describe the benefits that might accrue to either the subject or society. (Note that risks to participants must be reasonable in relation to the anticipated benefits. The investigator should specifically state the importance of the knowledge that reasonably may be expected to result from this research.)
 
 
 
 
Checklist for Application Submission:
 
( ) Research Plan*
( ) Completed IRB Application Form (incomplete forms will be returned without approval)
( ) Appropriate Signatures
( ) Informed Consent/Assent forms
( ) Outline or script to be provided prior to participant's agreement to participate (oral solicitation form)
( ) Instrument(s) [questionnaire, survey, testing]
( ) Debriefing form that will be provided upon participant's completion of the research
 
* Research plan should be a brief summary of research, the methodology, risks to participants, and benefits. This plan is used for any unfunded research, including thesis research.
 
Number of copies to be submitted (based on type of review required):
 
Exempt review - 2 copies plus original
Expedited review - 2 copies plus original
Full board review - 9 copies plus original
 
NOTE:
 
1. Any changes in the project after approval by the IRB must be resubmitted as a modification for review by the IRB before approval is granted. Modifications do not change the period of initial approval.
2. Approval is granted for a maximum of one year. Annual requests must be made to the IRB for continuation, as long as the research continues.
 
 
 
 
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