Fill - Institutional Review Board (SOWELA Technical Community College)

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Institutional Review Board

Cover Sheet for Approval of Research Using Human Subjects

Date of Request: ______________________

Title of research project: _________________________________________________________

Principal Investigator: _______________________________________________________________

Department: ___________________________ Phone:_______________________________

Email: ____________________________________________________________________________

Is this a student proposal? Yes No If yes, Faculty advisor: _______________________

Requested Review: Exempt Expedited Full Board

(

Complete #4 & 5) (Complete #4 & 5)

Does this project involve minors, pregnant women, prisoners, or other special populations? Yes No

Comments:

To Be Reviewed by:

IRB Date Received: ______________________

________________________________________________________________________

Request for Approval Using Human Subjects from Institutional Review Board (IRB)

1. Description of Project (attach additional information as needed)

a. Briefly describe the population of human subjects involved (e.g., students, community

members, school children, prisoners, pregnant women, etc.). Indicate if participation is

voluntary or not.

b. Briefly describe research procedures and data collection techniques (e.g., interview,

questionnaire, observation, etc.).

c. Briefly present the objectives of the research (e.g., present in lay terms hypothesis to be

tested)

2. Subject recruitment (in addition to the items checked below, submit verbatim copies of all

letters, notices, advertisements, etc. with an outline of all oral presentation to be used).

a. Direct person-to-person solicitation

b. Telephone solicitation

c. Newspaper solicitation

d. Letters of solicitation

e. Posted notices of solicitation

f. Other (explain)

g. List below all criteria for including subjects

h. List below all criteria for excluding subjects

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3. Benefits and costs to subjects.

a. Indicate what, if any, benefits may accrue to each of the following (note: financial

payment to subjects is considered a benefit).

i. Benefits to human subjects involved.

ii. Benefits to individuals who are not subjects and generalized benefits to society.

b. If subjects are to be paid, present financial details (amount, method of disbursement,

payment schedule, financial effect on subjects who withdraw from participation).

c. Estimated participation costs to each subject.

i. Time (total time commitment for duration of project)

ii. Money

4. Basis Of Claim For Exemption or Expedited Review. To qualify for an exemption from a Full

Board Review, at least one of the following must apply:

a. The research will be conducted only in established or commonly accepted education

settings (e.g., classrooms) and it involves normal educational practices such as research

on regular and special education instructional strategies, or research on the

effectiveness of, or the comparison among, instructional techniques, curricula or

classroom management methods.

b. The research will be conducted using only questionnaire or interview survey methods

and the subjects are elected or appointed public officials or candidates for public office.

c. The research is limited to the collection and study of existing data, documents, records

pathological or diagnostic specimens, available to the public.

d. The research is limited to the collection and study of data obtained using only the

following techniques and the data or information will be recorded in such a manner that

subjects cannot be identified, directly or indirectly through identifiers linked with the

subjects.

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_____________________________________________ ___________________

Check below the technique(s) which apply:

____ Data will be obtained through the use of education tests (cognitive, diagnostic,

aptitude, achievement, etc.).

____ Data will be obtained by observing the public behavior of subjects.

____ Data will be obtained through survey or interview procedures.

____ Data will be obtained from existing documents, records pathological or

diagnostic specimens.

e. The research is limited to the collection and study of data obtained by:

____ Observing the public behavior of the participants.

____ Using survey or interview procedures and (both of the following must apply if

this basis is to qualify for an exemption).

____ The information collected about the subjects’ behavior does not involve

sensitive subjects such as illegal or immoral conduct, drug or alcohol

use, sexual behavior, mental illness, or other possibly embarrassing

subjects.

AND

____ The information collected, if it became known to outsiders, could not

reasonably be expected to place the subjects at risk of civil or criminal

liability, or be damaging to the subjects’ social or financial standing or

employability.

5. Statement of Risk, Request/Recommendation for Exemption

The undersigned certify that they believe that the conduct of the above described research

constitutes no more than minimal risk of physical or emotional harm, or social or legal

embarrassment, to participating human subjects and request that the above described research

be considered exempt from full review by the SOWELA Institutional Review Board.

Principal Investigator(s) Date

Faculty Sponsor (if research is carried out by students) Date

Department Chair / Supervisor Date

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