Application for Human Research
(Social and Behavioral Research)
York College of Pennsylvania
Application Number
Investigators: leave blank for new applications.
Date of Original Application
(Only if this is a revision.)
Name of Primary Investigator
Today's Date
Format: 12/22/2014
Email Phone Number
Mailing / Campus Address
Title of Research Project
Other Investigators: Name and Contact Information
If any investigators are affiliated with institutions other than York, please indicate.
If you are a student, who is your professor and what course is this for?
If this is for a DNP scholarly project, please indicate so here.
If your research is funded by a grant, please provide the details. Include FDC funding.
(1) If your research involves participants from any special or vulnerable populations,
check all that apply.
Minors (any subjects under 18) Prisoners
Elderly Mentally disabled
Physically disabled
(2) Purpose of Study
(What is your research question? If you are testing a theory, what is that theory? If you are
doing exploratory research, describe the status of your project. etc.)
(3) Research Protocol: Describe how you plan to carry out your research.
(4) What personally identifiable information will you be collecting?
This can include names, student ID numbers, or social security numbers, but also information
like job titles, employers, or information about special training or abilities, that would allow third
parties to guess the identities of your research subjects.
(5) Will you promise your subjects that you will protect their privacy or personal
information? If so, what protections do you have in place for ensuring this?
(6) Will subjects receive any inducements before or rewards after the study? Is so,
please explain.
(7) Might subjects feel pressure to participate due to the circumstances under which you
are conducting your study? If so, please discuss methods you will use to ensure that
participation is voluntary.
(8) Please indicate all the methods you will use to inform participants of their rights.
Be sure to attach copies of all forms and protocols to your application.
introductory letter
survey questionnaire
interview (oral) -- include written protocol
interview (written/online) -- include sample materials
debriefing (oral) -- include written protocol
informed consent form
(9) Explain how each of the documents listed under question #8 will be used. (a) To
whom will it be administered? (b) Under what circumstances?
(10) Does your research involve any potentially SENSITIVE TOPICS?
questions about sexual behavior or attitudes
questions about the use of, or attitudes towards, drugs (including alcohol)
questions about an individual's violation of the law
presentation of material that may be considered vulgar, offensive, threatening, or
degrading to participants
(11) Does your research involve any PHYSICAL or PSYCHOLOGICAL RISKS?
administration of physical stimuli other than those normally encountered in a
typical classroom setting
manipulation of physiological requirements (such as nutrition or sleep)
physical exertion beyond what would normally occur in a classroom setting
study of ethically sensitive variables (such as stress or self-esteem)
exposure to potentially dangerous chemicals or objects
(12) If you checked any boxes in questions #10-11, please note here what aspect of your
project involves sensitive topics or risks, AND address how to intend to limit or
ameliorate them.
(13) (a) Where will you recruit subjects? (b) What method(s) will you use (letters, emails,
in-person presentations, asking people you know for names, etc)? Make sure to append
the text of all advertisements, letters, etc. (including scripts for audio spots).
(14) For EACH of the locations mentioned in (13a), discuss (a) why are you recruiting at
the sites you have chosen? (b) what procedures are you putting in place to limit undo
influence on potential subjects to participate in your research? (c) if the privacy of
potential subjects may be infringed through your process of recruiting subjects, discuss
any safeguards you will put in place.
(15) Will your subjects be INTENTIONALLY MISLED at any point during your research? If
so, please discuss here.
(16) How do you weigh any harm that your research subjects may sustain (or risks they
may encounter) against the possible benefits of your study?
(17) OPTIONAL. Sometimes investigators want to reference citations in their applications. You
are NOT expected to do so, much less to provide a literature review. But if you think that it may
help your reviewers to have full citations, please place them here.
Some examples: if you will be using a research protocol that is common in your field, you may
want to reference a source that gives a full discussion of it. Or if you need to address the
possible risks of a particular intervention, or ethical issues relating to a particular subject group,
you can use this space to refer reviewers to a fuller discussion of the issue.
version: 8-8-16