Exempt Application Revised 4/30/2010 Page 3 of 5
If your research will be observational, describe how the observations will be recorded (e.g.,
audio, video, field notes). If you are planning to audio or videotape the participants, please see
Section V. If videotaping, please explain how you plan to use and store the videotape(s). In
most cases, if your project involves videotaping, it will not qualify as exempt.
6. Describe your participant population (e.g., age, as special needs, etc…). How will you identify,
contact and recruit participants? How many participants do you intend to involve in your
research? How will you explain your research to participants?
1. Please provide a consent form
to be given to research participants. Examples can be found on the CHS
website under “Forms”.
a. If audio or video recordings will be a part of the research records, there must be a clear
description in the consent form of: 1) how the recordings will be used including any uses beyond
this research project, 2) how the recordings will be stored, 3) and what will be done with the
recordings when the project is complete. A separate consent form, or yes/no checkbox on the
main consent form must be provided so that participants can agree or refuse to be recorded.
b. As applicable, include language in the consent form that describes how the data or recordings
are likely to be used for future research purposes.
2. For research involving minors (ages 17 and younger), you must provide the following:
a. A parent/guardian consent form for their child to participate in research that includes space for a
signature and date.
b. A way of obtaining assent or refusal to participate from the child(ren) that is understandable to them.
If the participants are 5 to 11 years old, please provide an oral assent
script with an explanation of
how you will explain the project to them and obtain their assent or refusal to participate. If the
participants are 12 to 17 years old, please provide a written assent form that includes space for a
signature and date.
3. Attach a copy of all survey instruments and interview guides. If you are using recruitment flyers, or
advertisements, please provide copies of these as well. If draft instruments are submitted, final drafts
must be submitted for final CHS approval before use.
Approval of this Exempt Application is valid for the entire life of the research project and does not need to be
renewed annually. However, any changes in the procedures or instruments must be prospectively approved by
CHS, a process which can occur via email for Exempt projects. Once the study is complete, please notify CHS.
If you have questions, or you are unsure whether your research project is Exempt, please call the CHS
Office at (808) 956-5007, or send an inquiry by email to email@example.com
VI. How to Submit Your Application:
Please provide CHS with this application (typed and signed on page 4), a description of the project, and all
relevant documents listed in Section V. (Email is preferred for exempt applications. However, paper is accepted)
Email to: firstname.lastname@example.org. Subject line: “Exempt Application”. A signed application is required. To convert
your signed application to an e-file, please scan.
Mail or Deliver: Send/provide 2 copies of all materials (collated) with original signatures to UH Committee
on Human Studies, 1960 East-West Road, Biomedical Building B-104, Honolulu, HI 96822.
Fax to: (808) 956-8683, applications must be signed and dated.