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MOHAWK VALLEY COMMUNITY COLLEGE Request for Approval for (Mohawk Valley Community College)

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MOHAWK VALLEY COMMUNITY COLLEGE
Request for Approval for Use of Human Participants in Research
For use by Research Review Team (RRT) members only:
Proposal No: Date Received: Action Date:
Action Notes:
Reviewer Initials: Notification sent:
Email your completed application to the Chair of the Research Review Team (RRT). In
addition, sign and submit THE LAST PAGE ONLY as hard copy. (Students will also need to
have their faculty supervisor’s signature.) Proposals will not be approved unless a hard copy of
the signatures has been received. To ensure expeditious review of your project, please be as
specific and complete as possible in your responses, and include all necessary supporting
materials as appendices (e.g., consent forms, surveys, interview scripts, debriefing script).
Please email the application and appendices as a single document.
Date:
Principal Investigator: Course No., if applicable:
Phone Number: Email:
If Principal Investigator is a student:
Name of faculty supervisor: Email:
(Note: Faculty supervisor’s signature must appear at the end of this form. Faculty supervisor must
currently be employed by MVCC.)
Project Title:
Project involves (check all applicable; to check a box, double-click on it and follow instructions):
Faculty research
Student research in fulfillment of a course requirement (If for Honors course, please attach
copy of full research proposal)
Other (specify)
Anticipated Start Date: Anticipated End Date:
(Maximum length is one year; project approval must be renewed annually.)
A. NATURE OF THE PROJECT
A1. Briefly describe your research project. (If for Honors course, please attach copy of
full research proposal)
This information is important in weighing the benefits of the research against any risks that
might be incurred by the participants in the study. Keep in mind that RRT members are not
necessarily specialists in your field, so write for a general audience.
A2. Specify the procedure that will be used in the study.
Your description should include verbal statements that will be made to participants, particularly
any statements that will be misleading or deceptive. Please attach the following documents as
appendices to the proposal: (a) the experimenter’s script, (b) all written materials to be given to
participants, including questionnaires, surveys, or tests, (c) all interview questions, if applicable,
and (d) a copy of the debriefing script. Note that drafts of surveys or interview questions are not
acceptable; only final versions can be approved.
B. PARTICIPANT POPULATION
B1. All participants must be adults (age 18 or older)
B2. Institutional Affiliation of participants (check all applicable):
Due to HIPAA regulations, research involving off-campus institutions such as hospitals or
other social service agencies may ALSO require approval from that institution’s IRB.
Documentation of approval from external agencies may also be necessary.
No institutional affiliation outside of MVCC is involved
Schools (specify):
Hospitals (specify):
Other (specify):
B3. Estimated number of participants:
B4. How will the participants be solicited or contacted? (e.g., flyers, email, social
networking sites, telephone, announcements made in courses, online recruitment program, etc.)
C. RISKS
C1. Is it possible that the participants will incur any psychological, social, physical, or
legal risk? This includes any psychological distress associated with experimental
manipulations.
yes
no
If yes, please explain the nature of the risk and why it is necessary. Is there any
alternative way of conducting the research that would be less risky to participants? If so,
why have you not chosen the alternative?
C2. What steps will be taken to minimize the risks to participants?
C3. Will the participants be deceived or misled in any way?
yes
no
If yes, please explain the nature of the deception and why it is necessary.
C4. Will there be any probing (either verbal or written) for information that
participants might consider to be personal or sensitive?
yes
no
If yes, please explain the nature of the information.
C5. Is it possible that the participants will be presented with materials, or be exposed to
social interactions, that they might consider to be offensive, threatening, or
degrading?
yes
no
If yes, please explain the nature of the materials or social interactions. Is there any
alternative way of conducting the research that would be less offensive, threatening, or
degrading to participants? If so, why have you not chosen the alternative?
D. VOLUNTARY PARTICIPATION/INFORMED CONSENT
(The questions in this section do not apply to unobtrusive observation of public behavior.)
Federal law requires that, except in special circumstances, informed consent must be obtained. In brief,
consent forms must (1) explain the purpose, procedures, and duration of the project, (2) describe the
benefits to the participant and others, (3) state any risks involved, (4) describe the manner in which
confidentiality will be maintained, (5) provide contact information should questions arise in the future,
and (6) state that participation is completely voluntary. Web-based surveys should include a consent
form in which respondents check a box to indicate consent.
D1. Will a written or online consent form be used?
yes
no*
*If a consent form is not to be used, you must provide justification. Even if you do not use a
consent form, you must still provide participants with a written statement about the research
and the contact information of the researcher, supervisor, and the Director of Institutional
Research and Analysis.
D2. What information about the study will be provided to potential participants? If it
is necessary to obtain participation without informing participants of the true nature of
the study, include a script for information to be provided by research personnel or
written material to be given to participants prior to or at the outset of the study.
D3. If research involves participant observation, how will the researcher’s role be
explained to other participants in observed activities?
E. CONFIDENTIALITY/ANONYMITY
E1. Will data be collected that identifies individuals or be
recorded
in a way that allows observations to be linked to individuals?
yes
no
If yes, please explain the nature of the information.
E2. Will any personal data be drawn from institutional files or archives (e.g., school
files)? If yes, explain the source and nature of such data. Please note that your consent
form must specifically ask permission to gather such data.
E3. Who will have access to the data from the study?
E4. What steps will be taken to insure confidentiality of personal data?
Be specific. Will research personnel (including students) be informed of their
responsibilities in maintaining confidentiality? How will confidentiality be preserved as
data are collected, stored, analyzed, and published? When will data identifying
individual participants be destroyed?
F. Is this research part of :
Honors project
MVCC course requirement
Leadership Academy
Other:________________________________________________
If Other, how does this project benefit MVCC?
MOHAWK VALLEY COMMUNITY COLLEGE
Request for Approval for Use of Human Participants in Research
ASSURANCE STATEMENT
Complete this page, sign, and submit a hard copy to the Chair of the RRT.
Project Title:
Principal Investigator: Email:
Name of Faculty Supervisor (if applicable): Email:
FOR PRINCIPAL INVESTIGATOR:
I confirm that the procedures described above are accurate and will be followed in the course of the
research project. I will notify the RRT of any changes to procedures and if unanticipated problems
arise during the research process.
Signature of Principal Investigator
Date: ________________________
FOR FACULTY SUPERVISOR:
If principal investigator is a student, the faculty supervisor must also sign:
I have reviewed this completed application and find it acceptable with respect to the research design
and the protection of human participants.
Signature of Faculty Supervisor
Mohawk Valley Community College
1101 Sherman Drive
Utica, NY 13501
Sample Participant Consent Form
Purpose:
The purpose of this study is to examine the types of thoughts a person may experience while performing a task. The study
is part of XXX senior thesis in psychology, under the supervision of Professor ZZZ.
Procedure:
If you agree to be in this study, you will be asked to do the following:
1. Listen to approximately 13 minutes of music (36 short melodies).
2. Report the emotion you associate with the music.
3. Complete a questionnaire in which you rate the frequency with which you have had certain types of thoughts.
The total time required to complete the study should be approximately 30 minutes.
Benefits/Risks to Participant:
Participants will learn about the empirical methodologies of and will help contribute to the body of knowledge in
psychology. Risks include any discomfort you may feel while listening and rating the melodies, or responding to personal
questions.
Voluntary Nature of the Study/Confidentiality:
Your participation in this study is entirely voluntary and you may refuse to complete the study at any point during the
experiment, or refuse to answer any questions with which you are uncomfortable. You may also stop at any time and ask
the researcher any questions you may have. Your name will never be connected to your results or to your responses on the
questionnaires; instead, a number will be used for identification purposes. Information that would make it possible to
identify you or any other participant will never be included in any sort of report. The data will be accessible only to those
working on the project.
Contacts and Questions:
At this time you may ask any questions you may have regarding this study. If you have questions
later, you may contact XXX at 555-555-5555 or XXX@mvcc.edu or her faculty supervisor, ZZZ
at 555-555-5555 or ZZZ@mvcc.edu. Questions or concerns about institutional approval should
be directed to Marie Miknavich, Director of Institutional Research and Analysis, 315-792-5467
or mmiknavich@mvcc.edu.
Statement of Consent:
I have read the above information. I have asked any questions I had regarding the experimental procedure and they have
been answered to my satisfaction. I consent to participate in this study.
Name of Participant_________________________________________Date: __________
(please print)
Signature of Participant ____________________________________________
Age: (Note: You must be 18 years of age or older to participate in this study. Let the experimenter know
if you are under 18 years old.)
Thanks for your participation!
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MOHAWK VALLEY COMMUNITY COLLEGE Request for Approval for (Mohawk Valley Community College)

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Completed 21 September 2020

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