Fillable DEPARTMENT HEAD APPROVAL FORM TO: Project Directors FROM: (Louisiana Tech University)

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DEPARTMENT HEAD APPROVAL FORM TO: Project Directors FROM: (Louisiana Tech University)

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DEPARTMENT HEAD APPROVAL FORM
TO: Project Directors
FROM: Barbara Talbot, Office of Sponsored Projects
btalbot@latech.edu
318-257-5075 phone
318-257-5079 fax
http://research.latech.edu/
SUBJECT: HUMAN USE COMMITTEE REVIEW
Please submit this page, signed by yourself, and your Department Head or Dean,
when submitting a proposal to the Human Use Committee for expedited approval.
Your signatures are stating that you are aware of this proposal and/or survey
being conducted, and all aspects of the study comply with the appropriate
University Policies and Procedures.
Department
F
aculty Member Serving as Principal Investigator Signature Date
S
tudent Researcher (If applicable) Academic Program Date
D
epartment Head Name
Department Head - Please check one box:
I approve this project I do NOT approve of this project moving forward
Department Head Signature Date
NOTE: If using a digital signature, you will be asked to s
ave as a new PDF filename upon signing.
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signature
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LOUISIANA TECH IRB SUBMISSION FORM
Submit to Barbara Talbot at btalbot@latech.edu
Please allow time for Processing
STUDY/PROJECT INFORMATION FOR HUMAN SUBJECTS COMMITTEE
Describe your study/project in detail for the Human Subjects Committee.
Please include the following information:
TITLE:
PROJECT DIRECTOR(S):
EMAIL: PHONE:
DEPARTMENT(S):
PURPOSE OF STUDY/PROJECT:
SUBJECTS:
DETAILED PROCEDURE:
Do you plan to publish this study? □ YES □ NO
Will this study be published by a national organization? □ YES □ NO
Are copyrighted materials involved? □ YES □ NO
Do you have written permission to use copyrighted materials? □ YES □ NO
Researchers must comply with all training requirements from their funding agency.
Are all Researchers Up to Date on Human Subjects Training? (attach certificates)
Training is on www.citiprogram.org □ YES □ NO
Do any Special Permissions Need to be attached? (School district, data holder, Agency) □ YES □ NO
INSTRUMENTS AND MEASURES TO INSURE PROTECTION OF
CONFIDENTIALITY, ANONYMITY:
RISKS/ALTERNATIVE TREATMENTS:
BENEFITS/COMPENSATION:
SAFEGUARDS OF PHYSICAL AND EMOTIONAL WELL-BEING:
HUMAN SUBJECTS CONSENT FORM
The following is a brief summary of the project in which you are asked to participate. Please read
this information before signing the statement below. You must be of legal age or must be co-
signed by parent or guardian to participate in this study.
TITLE OF PROJECT:
PURPOSE OF STUDY/PROJECT:
SUBJECTS:
PROCEDURE:
BENEFITS/COMPENSATION:
RISKS, DISCOMFORTS, ALTERNATIVE TREATMENTS:
The participant understands that Louisiana Tech is not able to offer financial
compensation nor to absorb the costs of medical treatment should you be injured as a
result of participating in this research.
The following disclosure applies to all participants using online survey tools: This server
may collect information and your IP address indirectly and automatically via “cookies”.
I, , attest with my signature that I have read and
understood the following description of the study, "( )”,
and its purposes and methods. I understand that my (Or my Child’s) participation in this
research is strictly voluntary and my (or my child’s) participation or refusal to participate
in this study will not affect my relationship with Louisiana Tech University or my grades
in any way. Further, I understand that I may withdraw (my child) at any time or refuse to
answer any questions without penalty. Upon completion of the study, I understand that
the results will be freely available to me upon request. I understand that the results of
the material will be confidential, accessible only to the principal investigators, myself, or
a legally appointed representative. I have not been requested to waive nor do I waive any
of my rights related to participating in this study.
Signature of Participant or Guardian Date
Name of child if Applicable
CONTACT INFORMATION: The principal experimenters listed below may be reached to
Answer questions about the research, subjects' rights, or related matters.
PRINCIPAL INVESTIGATOR:
CO-INVESTIGATOR:
Members of the Human Use Committee of Louisiana Tech University may also be
contacted if a problem cannot be discussed with the experimenters:
Dr. Richard Kordal, Director, Office of Intellectual Property & Commercialization
Ph: (318) 257-2484, Email: rkordal@latech.edu
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Example Application and Consent Document: Do not submit
Describe your study/project in detail for the Human Subjects Committee. Please
include the following information.
TITLE: An exploration of personality characteristics and mood state.
PROJECT DIRECTOR(S): Professor XYZ
EMAIL: xxx
PHONE: xxx
DEPARTMENT(S): Behavioral Sciences
PURPOSE OF STUDY/PROJECT: To determine the relationship, if any, between
socialized personality characteristics and mood state.
SUBJECTS: Louisiana Tech University students selected from psychology classes.
PROCEDURE: Approximately 200 students from introductory psychology classes will
voluntarily complete a packet of self-report inventories, including a sex role
questionnaire, a depression inventory, and a self-efficacy survey. Data will then be
analyzed to determine the relationship among these variables.
INSTRUMENTS AND MEASURES TO INSURE PROTECTION OF
CONFIDENTIALITY, ANONYMITY: The 21 items Beck Depression Inventory (BDI)
developed by Aaron T. Beck will be used to assess mood. The Bem Sex-Role
Inventory (BSRI), a 60 item inventory developed by Sandra Bem, will be utilized to
assess sex-role. The 27 item Self-Efficacy Scale (SES) developed by Robert Tipton
and Everett Worthington will be used to measure self-efficacy. Additionally, a brief self-
report instrument developed by the researchers will be used to collect demographic
information and additional characteristics. Names will not be linked to surveys, and
consent forms will be kept separately.
RISKS/ALTERNATIVE TREATMENTS: There are no known risks at this time other
than normal everyday risks. The participant understands that Louisiana Tech is not able to
offer financial compensation nor to absorb the costs of medical treatment should you be injured
as a result of participating in this research.
BENEFITS/COMPENSATION: None
SAFEGUARDS OF PHYSICAL AND EMOTIONAL WELL-BEING: This study involves
no treatment or physical contact. All information collected from the survey will be held
strictly confidential. No one will be allowed access to the survey other than the
researchers.
Consent Form Sample:
This is a sample consent form: informed consent should be designed and presented in such a way that
facilitates a potential subject’s understanding of why one would want to participate in a research study or
not, and explain the risks and benefits in participation if any. You may use your own template or edit this
version. Please submit the final copy of exactly what your subjects will see and or sign. Be sure all
procedures involving the participants are listed specifically. Include photographing, recording, filling out
surveys, submitting materials, interviewing, etc. (see sample form)
Note: You may need to remove or add information based on your research.
HUMAN SUBJECTS CONSENT FORM
The following is a brief summary of the project in which you are asked to participate. Please read
this information before signing the statement below. You must be of legal age or must be co-
signed by parent or guardian to participate in this study.
TITLE OF PROJECT: An exploration of personality characteristics and mood state.
PURPOSE OF STUDY/PROJECT: To determine the relationship, if any, between
socialized personality characteristics and mood state
SUBJECTS: Psychology freshman level students
PROCEDURE: (Give a step by step Process of what the participants will asked to
do) You voluntarily complete a packet of self-report inventories, including a sex role
questionnaire, a depression inventory, and a self-efficacy survey. This will take
approximately 20 minutes. Data will then be analyzed to determine the relationship
among these variables. All information will be kept strictly confidential, with no way to
identify the participant. Individual results will not be shared.
BENEFITS/COMPENSATION: By participating in this study, we can gain better
knowledge in the relationship of socialized personality characteristics and mood, which
in turn may help gain a better understanding in social diseases.
RISKS, DISCOMFORTS, ALTERNATIVE TREATMENTS: There are no risks
associated to this study, but some questions may be personal in nature. You may skip
any questions that may make you feel uncomfortable.
The participant understands that Louisiana Tech is not able to offer financial compensation nor to
absorb the costs of medical treatment should you be injured as a result of participating in this
research.
The following disclosure applies to all participants using online survey tools: This server may
collect information and your IP address indirectly and automatically via “cookies”.
I, ___________________, attest with my signature that I have read and understood the
following description of the study, “(An exploration of personality characteristics and mood state)",
and its purposes and methods. I understand that my participation in this research is strictly
voluntary and my participation or refusal to participate in this study will not affect my relationship
with Louisiana Tech University or my grades in any way. Further, I understand that I may
withdraw at any time or refuse to answer any questions without penalty. Upon completion of the
study, I understand that the results will be freely available to me upon request. I understand that
the results of my survey will be confidential, accessible only to the principal investigators, myself,
or a legally appointed representative. I have not been requested to waive nor do I waive any of my
rights related to participating in this study.
________________________________ _____________
Signature of Participant or Guardian Date
CONTACT INFORMATION: The principal experimenters listed below may be reached to
answer questions about the research, subjects' rights, or related matters.
Principal Investigator: ________________________________________________________
Co-Investigator: ___________________________________________________________
Members of the Human Use Committee of Louisiana Tech University may also be contacted if a
problem cannot be discussed with the experimenters:
Dr. Richard Kordal, Director, Office of Intellectual Property & Commercialization
Ph: (318) 257-2484, Email: rkordal@latech.edu
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DEPARTMENT HEAD APPROVAL FORM TO: Project Directors FROM: (Louisiana Tech University)

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Completed 23 July 2020

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