Fillable IRB APPLICATION FOR USE OF HUMAN SUBJECTS IN (Presbyterian College)

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IRB APPLICATION FOR USE OF HUMAN SUBJECTS IN (Presbyterian College)

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IRB Application w Page 1/2
IRB APPLICATION FOR USE OF HUMAN SUBJECTS IN RESEARCH
(Please submit all documentation electronically)
TO: IRB Chairperson, Presbyterian College
DATE:
INVESTIGATOR(S):
DEPARTMENT:
PROJECT TITLE:
FUNDING AGENCY:
THE FOLLOWING TYPE OF REVIEW IS REQUESTED: (_) IN-CLASS RESEARCH ( ) EXEMPTION ( ) EXPEDITED ( ) FULL
Please underline the most appropriate answer for each question. Do not leave any questions unanswered.
1. Will human subjects be participating in:
a. biomedical procedures? ....................................................................................... NO YES
b. procedures to elicit information (personality tests, questionnaires,
inventories, surveys, observations, etc.)? ............................................................... NO YES
c. procedures specifically designed to directly modify the knowledge,
thinking, attitudes, feelings, or other aspects of the behavior
of subjects? ............................................................................................................. NO YES
2. If biomedical procedures are involved:
a. are provisions for emergency medical care necessary? ....................................... NO YES N/A
(if yes, give details on the Proposal Form)
b. has a qualified MD participated in planning the project? ...................................... NO YES N/A
c. will this study involve drugs or chemical agents (dosages),
ionizing radiation, nonionizing radiation (microwaves, lasers),
or high intensity sound? ......................................................................................... NO YES N/A
3. Does this study involve giving false or misleading information to
subjects or withholding information from them such that their
"informed consent" is in question? ................................................................................ NO YES
4. Are procedures to be used new or innovative (not established and
accepted)? ...................................................................................................................... NO YES
5. Will the procedures:
a. cause any degree of discomfort, harassment, invasion of privacy,
risk of physical injury, or threat to the dignity of subjects, or be
otherwise potentially harmful to subjects? ............................................................ NO YES
b. if answer to 5a is yes, have specific provisions been made to
correct any harmful or adverse conditions that may arise? .................................... YES NO N/A
(Give details in the Proposal Form).
6. Can the potential benefits to subjects from conducting this study be
considered to outweigh the risks to subjects? ................................................................ YES NO N/A
7. Can the potential benefits to society from conducting this study be
considered to outweigh the risks to subjects? ................................................................ YES NO
IRB Application w Page 2/2
8. Will subjects come in direct contact with any type of electrically powered
equipment? (If the answer is yes, give in the Proposal Form the
name and qualifications of the individual who will check for
electrical safety and attach a signed letter from that person which
indicates his/her level of involvement with the project.) ............................................... NO YES
9. Will subjects receive any payment for participating (money, course
credit, extra credit, etc.)? (If answer is yes, give details in the Proposal Form.) .......... NO YES
10. Is the project specifically designed to involve subjects who are:
a. minors (less than 18 years of age)? ........................................................................ NO YES
b. pregnant women? ................................................................................................... NO YES
c. prisoners? ............................................................................................................... NO YES
d. mentally retarded? .................................................................................................. NO YES
e. mentally disabled (e.g., brain-injured, psychiatric patients, etc.)? ........................ NO YES
f. physically disabled (e.g., uses wheelchair, walker, etc.)? ...................................... NO YES
g. institutionalized? .................................................................................................... NO YES
h. Presbyterian College students? .............................................................................. NO YES
11. Do procedures include obtaining parental/guardian consent and/or
institutional authorization for access to subjects if minor, mentally
retarded/disabled, or institutionalized subjects are involved? ....................................... YES NO N/A
12. Are procedures for maintaining confidentiality of all subjects' data
fully described? .............................................................................................................. YES NO
13. Are procedures for obtaining informed consent fully described? .................................. YES NO
14. Will a copy of the informed consent document and explanation of
the study be provided to each subject? .......................................................................... YES NO
15. Have copies of informed consent documentation been submitted
along with the protocol (i.e., signature document with explanation
of study, transmittal letter, debriefing statement, or other)? .......................................... YES NO
16. Will any non-Presbyterian College site(s) be included in data collection? .................. YES NO
17. Fill in the estimates:
Average amount of time required for subject's participation (in hours) ........................
If questionnaires or tests are involved, the total number of items .................................
Number of volunteers (subjects) to be involved in this study .......................................
and ending date
of involvement.
We certify that the project or activity described in the attached information was planned to adhere to the College’s policies regarding the
use of human subjects. College review and approval is requested. Major additions to or changes in procedures involving human subjects
that occur after review of the application will be brought to the attention of the review committee by the investigator. In addition, the
committee will be notified of any unanticipated events that do or could affect the safety and well being of subjects. IRB approval is valid
for a period of one year from the date that the approval is issued.
Principle Investigator's Name
Address
Phone
Signature
†
Faculty Adviser's or Sponsor's Name
Address
Phone
Signature
Division or Unit Chair's Name
Address
Phone
Signature
IRB Application w Page 3/2
†
Student projects must be supervised by a full-time Presbyterian College faculty member. Although non-Presbyterian College
investigators may be involved in a project in any capacity, all projects must be sponsored by a full-time Presbyterian College faculty
member who is ultimately responsible for the safe conduct of the study.
To avoid delays, do not leave any items blank on forms and make sure to provide all information needed to complete the review
process. Submit completed electronic forms to IRB@presby.edu.
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IRB APPLICATION FOR USE OF HUMAN SUBJECTS IN (Presbyterian College)

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Completed 23 July 2020

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