PEARL RIVER COMMUNITY COLLEGE
Petition to Institutional Review Board
(Petition Must Be Typed)
New Application Renewal Application
Name of Principal Investigator: _______________________________________________________________________
Professional Email address: _________________________ Personal Email Address: ____________________________
Telephone Number: _______________________
Name of Co-Investigator:____________________________________________________________________________
Telephone Number: _______________________ Email address:_______________________________________
Name of Co-Investigator:____________________________________________________________________________
Telephone Number: _______________________ Email address:_______________________________________
Purpose of Project (Dissertation, Class Project/Assignment, etc.): ____________________________________________
Project Duration – From: __________________________________ To: ____________________________________
Project Title: _____________________________________________________________________________________
Funding Agency and Proposal ID Number (if any): _______________________________________________________
Conflict of Interest: Investigators __ do or __ do not have a real or potential conflict of interest.
D
oes this project meet condition (a) or (b) outlined below that will make it exempt from full Board review?
____Yes ____ No
a. Mi
nor changes in previously authorized research during the period for which approval is authorized.
b. R
esearch involving survey or interview procedures where all of the following conditions (Common Rule Section 10
1
s
ubsection b) occur:
• Responses are recorded in such a manner that human subjects cannot be identified, directly or throug
h
identifiers linked to the subjects.
• The subject's responses, if they become known outside of the research, would not place the subject at risk of
civil or criminal liability or be damaging to the subject's financial standing or employability.
• The research does not deal with sensitive aspects of the subject's own behavior, such as illegal conduct, drug
use, sexual behavior, or use of alcohol, and is not likely to cause the subject undue stress, fatigue, or any other
psychological reactions.
• The research proposal makes adequate provision for obtaining the informed and voluntary participation of
subjects.
Include a brief statement of how human subjects are involved in the project:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
P
roject Summary attached? ____ Yes ____ No
Project Proposal attached? ____ Yes ____ No
I
understand and agree to the following: Study findings must be shared with the Pearl River Community College (PRCC)
Institutional Review Board. Copies of the report may be shared with both internal and external personnel associated with
the College who have an interest in the topic and results. In addition, permission of the PRCC Institutional Review Board
is required prior to publication of results of such study. Approval is at the sole discretion of the Board.
Principal Investigator Signature: _______________________________________________ Date:_________________
Print Name: ______________________________________________________________________________________
11/17
