Fillable IRB PROTOCOL FORM (Broward College)

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IRB PROTOCOL FORM (Broward College)

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The IRB PROTOCOL FORM (Broward College) form is 6 pages long and contains:

  • 4 signatures
  • 37 check-boxes
  • 45 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Broward College

BROWSE BROWARD COLLEGE FORMS

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IRB-PF – (10/16) Page 1 of 6
Please select the type of review you believe your study requires:
Exempt
Expedited
Full Board
Section I General Study Information
Title of Study:
Name of Primary Investigator (PI):
Is the PI affiliated with Broward College? Yes No
If yes, in what capacity?
Phone:
Email:
For the purposes of this research is the PI affiliated with another institution? Yes No
If yes, which institution and in what capacity?
Name of Co-Investigator (if applicable):
Is the Co-Investigator affiliated with Broward College? Yes No
If yes, in what capacity?
Phone:
Email:
For the purposes of this research is the Co-Investigator affiliated with another institution?
Yes No
If yes, which institution and in what capacity?
Source of Funding (select all that apply):
Internal Grant (specify):
External Grant (specify):
Unfunded
Other (specify):
International Research (select one):
N/A
Mark here if the research will be conducted outside of the US
Mark here if the study has been reviewed or will be reviewed by an international IRB or ethics board
IRB PROTOCOL FORM
IRB-PF – (10/16) Page 2 of 6
Section II Study Summary and Rationale
Study Summary (include a general overview of the summary in non-scientific language; not to exceed 250 words):
Study Background & Purpose (include pertinent background information, rationale for the study, study objectives,
research questions or hypotheses; not to exceed 500 words):
IRB-PF – (10/16) Page 3 of 6
Section III Study Design
Provide a detailed description of the procedures that will occur in sequential order. If applicable include recruitment,
consenting participants, intervention, number and duration of contacts with participants, data collection, and data
analysis:
Explain how you will ensure the safety of the data. If applicable include what data will be stored, how the data will
be stored, who will have access to the data, how the data will be coded, and when data will be destroyed:
IRB-PF – (10/16) Page 4 of 6
Section IV Participants
Participant Gender (select all that apply):
Female
Male
Transgender
All genders
Participant Race/Ethnicity (select all that apply):
Asian
Black
Hispanic
Native American
White
Mixed Race/Ethnicities
All Races/Ethnicities
Participant Age (select all that apply):
Minors (under 18 years of age)
Adults (18 years or older)
Please list all languages that will be used to conduct the study (in interviews, consent forms, etc.):
Vulnerable populations (select all that apply):
Minors
Pregnant women
Individuals with disabilities
Homeless persons
Prisoners or those on probation or parole
Economically disadvantaged persons (i.e. students receiving Pell grant)
Educationally disadvantaged persons (i.e. students in need of remediation)
If conducting research with a vulnerable population, please explain the additional measures you will take to ensure
informed consent is obtained without coercion:
IRB-PF – (10/16) Page 5 of 6
Inclusion/Exclusion criteria (explain who you will and who you will not include in your study and what criteria will you
use i.e. GPA, life circumstances, major, race):
Please list your anticipated sample size (please note if you are approved and need to exceed this number at a later
date, an addendum will need to be submitted and approved to increase the sample size):
When do you anticipate starting data collection (please specify a date)? What is your estimated timeframe for
conducting this research (Disclaimer: data collection cannot commence until IRB approval is obtained)?
Section V Risks & Benefits
Please explain the risks of participation in this study:
Please explain the personal benefits to the participants (compensation for participants’ time is not a benefit) and
societal benefits from the research generally:
IRB-PF – (10/16) Page 6 of 6
Section VI Additional Documents
Please select any applicable documents that you have submitted with this protocol:
NIH Protecting Human Research Participants certificate of completion (required)
Survey(s), questionnaire(s), interview guide(s)
Consent form(s)
Recruitment flyer(s)
Recruitment email(s)
Recruitment speech(es)
Dissertation proposal/prospectus
Letter of Support(s)
Other IRB approval(s)
Other (specify)
CERTIFICATION
I certify that the information provided entirely and accurately describes the proposed research protocol. I agree not
to make changes to the protocol without first seeking IRB approval, except in the case of immediate harm to
participants. I agree to conduct research in accordance with applicable federal guidelines. I agree to immediately
report any unanticipated problems or adverse events to the IRB as soon as they are discovered.
I understand that the receipt of approval from the IRB Committee does not necessarily guarantee that I will be
provided with the research data requested. Approval of this research project is potentially subject to additional
review by the Broward College Registrar and Institutional Research, who may, if the research is not in the best
interest of the college, deny approval. If the IRB Committee denies approval, the decision cannot be overturned. If I
am an employee of Broward College, my immediate supervisor is aware of my intent to conduct this research.
PI name:
PI signature:
Date:
Supervisor name (if applicable):
Supervisor signature (if applicable):
Date:
Co-Investigator name:
Co-Investigator signature:
Date:
Supervisor name (if applicable):
Supervisor signature (if applicable):
Date:
Completed IRB Protocol Forms should be submitted with required and supporting documents to irb@broward.edu in
one communication.
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IRB PROTOCOL FORM (Broward College)

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Completed 18 August 2020

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