Exempt Review Application
Institutional Review Board
Date Submitted
Title of Research Project
Contact
Information
Principal Investigator/
Project Director
Co-Investigator/Student
Investigator
Co-Investigator/Student
Investigator
Name
Department
Phone Ext.
Email
Anticipated Funding Source (if applicable): ___________________________
Projected Duration of Research: months Projected Starting Date:
Other organizations and/or agencies, if any, involved in the study: ______________________________
EXEMPT UNDER CODE (see Exempt Review Checklist check one):
1
2
3
4
5
6
Clear Form
Exempt Review Application
Institutional Review Board
Summary Abstract: Please attach a document that supplies the following information:
BRIEF description of the rationale or purpose of the study
, the participants, the location(s) of the
project, the procedures to be used for data collection, whether data will be confidential or anonymous,
how the data will be used and shared, and data disposition procedures.
Does the study require class time? (Note: using class time is discouraged.) If so, do you have an
internal contact person who is willing to comply? Attach a confirmation of this agreement.
Attach a copy of the Informed Consent Form and the measures (questionnaires/surveys) to be used in
the project.
If another IRB is involved in your project, attach copies of the IRB submission and approval
documents.
Responsibilities of the Principal Investigator:
A
ny additions or changes in procedures in the protocol will be submitted to the IRB for writt
en
appr
oval before these changes are implemented.
Any problems connected with the use of human subjects once the project has begun must be
communicated to the IRB Chair.
The principal investigator is responsible for retaining informed consent documents for a period
of three years after the project.
The principal investigator should include with the IRB submission a confirmation that t
he
r
esearch has been approved by the HFC Dean or Director of the academic or functional
area(s) where the research will be conducted.
The principal investigator shall notify the HFC IRB chairperson when the research proposal
has been approved or modified by another institution’s IRB.
The principal investigator will provide a copy of the final research results to the chairperson of
HFC’s IRB.
Exempt Review Application
Institutional Review Board
Principal Investigator Signature: Date:
Co-Investigator/Student Signature (if applicable): Date:
Dean/Director Signature (if applicable): Date
Vice President Signature (if applicable): Date
Signature of IRB Committee Chair:
Date:
IRB Chair: Check one
Approved
Approved with conditions
Refer to Expedited
Refer to Full Committee