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IRBFORMC (Southern College)

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F
ORM C
CERTIFICATION for STUDENT CLASS PROJECTS
I
nstructor’s Assurance: By submitting this application, I attest that I am aware of the applicable principles,
policies, regulations, and laws governing the protection of human subjects in research and that I will
ensure that all student projects adhere to these principles. I also certify that all students submitted a
completed FORM A application for review and that all human subjects’ protections were met. I also
certify that I will maintain these forms for no less than three years and I understand that the Chair of the
IRB may periodically audit my records. I also certify I have completed CITI training and have granted
academic credit for these students to complete CITI training.
All forms should be submitted by email to irb@southern.edu
.
Cl
ass Name and Number: _____________________________________________________________
_
_____________________________________ ____________________________
Instructor Signature: Date
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, submit Form A to the IRB
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
For IRB Use Only:
Tracking Number __________________
Date Submitted __________________
Date Approved ___________________
Title of Class: __________________________________________________________________________
Instructor __________________________________________________________________________
Semester ____________________
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signature
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Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
Student Name(s)
Title of Project
Informed Consent Attached
Yes _____
Confidentiality Assured
Yes ____
Study is Minimal Risk
Yes _____ If no, contact IRB Chair for other application
Permission was obtained from other sites to conduct research (if applicable) Yes ____
Students will complete any CITI trainings related to their studies Yes ____
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IRBFORMC (Southern College)

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Completed 21 July 2020

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