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Appendix 5 2 Funded APPENDIX 5

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APPENDIX 5.2
Application Form for
FUNDED RESEARCH—CALIFORNIA STATE UNIVERSITY, FRESNO
COMMITTEE ON THE PROTECTION OF HUMAN SUBJECTS
Please type
PRINCIPAL INVESTIGATOR____________________________________________________________________________
Name Dept. (unit) Mail Stop Number
________________________________ _________________________________
Telephone Number Dept. Telephone Number
Student’s name or collaborator(s)___________________________________________________________________________
(if applicable) (if a graduate school thesis, so indicate) (affiliation if collaborative research)
__________________________________ _________________________________
Telephone Number Telephone Number
FUNDING SOURCE_____________________________________________________________________________
Is the California State University, Fresno Grants Office forwarding the request for funding? No_____ Yes_____
TITLE__________________________________________________________________________________________________
The Principal Investigator is responsible for fully understanding the Policy and Procedures of the CPHS. Below indicate
your judgment as Principal Investigator as to the RISK category of the present study. (See definitions on the reverse of this
sheet.) (If exempt see 3.52)
Minimal Risk _____
PROCEDURES
1. Attach your protocol and submit to your de-
partment chair for review by your human
subjects committee.
2. Your departmental committee concurs with
the Principal Investigator that the study is
“minimal risk” (see Appendix 5.3), then
3. The department chair should forward the
packet of materials with this form and the
departmental review forms to the
University CPHS, Thomas Administration,
Room 121, M/S TA52, for expeditious
review and “certification to the funding
source.”
4. The researcher will receive notice of
“certification” usually within 72 hours.
HOWEVER,
(If the departmental review changes the
determination to “At Risk,” follow the procedure
to the right of this page.)
At Risk _____
PROCEDURES
1. Attach your protocol and submit to your
department chair for review by your
human subjects committee. (A sample
informed consent must be included.)
2. Submit the department review form(s)
with this form to the CPHS.
3. Transmit all reviews and ten (10) copies
of the protocol to the CPHS for review.
Send one additional copy to the Dean.
4. Allow two weeks during the school
year for your response from the
CPHS.
"Exempt" Research.
If "exempt", see Section 3.5.2.
"Minimal Risk" Research.
Research IN WHICH THE RISKS OF HARM ANTICIPATED ARE NOT GREATER, PROBABILITY AND
MAGNITUDE, THAN THOSE ORDINARILY ENCOUNTERED IN DAILY LIFE OR DURING THE PERFORMANCE
OF ROUTINE PHYSICAL OR PSYCHOLOGICAL EXAMINATIONS OR TESTS. No research involving any item listed
as being "at risk" can be determined to be minimal risk. A department or other unit review committee may determine that a
research proposal submitted, in the judgment of the principal investigator as "minimal risk," is actually "AT RISK."
"At Risk" Research.
"A subject is considered to be 'at risk' if he/she is exposed to the possibility of harm- physical, psychological, sociological, or
other as a consequence of any activity that goes beyond the application of those established and accepted methods necessary
to meet his/her needs. The determination of when an individual is 'at risk' requires application of sound professional judgment
of the activity in question and the ethical principles contained herein. Responsibility for this determination resides at all
levels of institutional and departmental review.”
(The Institutional Guide to DHEW Policy on Protection of Human Subjects, Washington, D.C.,
1971, p.2.)
An illustrative, but not inclusive, list of "at risk" procedures would include experiments involving any aspect, degree, quality,
or amount of any of the following:
Deception, mental stress, including subjection to public embarrassment, humiliation, discomfort, irritation, or
harassment, hypnosis, sensory deprivation, sleep deprivation, normally ingested or inhaled materials in excess or
less than normal amounts, injection, ingestion or inhalation of toxic materials, including all drugs, alcohol or
placebos; strenuous physical exertion; use of physical stimuli in abnormal amounts (e.g., noise, vibration, shock,
heat, magnetic fields, radiation); violation of anonymity or confidentiality of subjects and data; OBSERVATIONS
RECORDED ABOUT THE INDIVIDUAL WHICH, IF THEY BECAME KNOWN OUTSIDE THE RESEARCH,
COULD MAKE THE SUBJECT LIABLE TO CRIMINAL OR CIVIL ACTION OR DAMAGE THE SUBJECT'S
FINANCIAL OR EMPLOYMENT STATUS; OR ABROGATION OF ANY CIVIL RIGHT.
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Appendix 5 2 Funded APPENDIX 5

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Completed 18 February 2020

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