UNIVERSITY OF ARKANSAS-FORT SMITH
Human Research Exempt Certification Form
To Be Completed Only If Protocol is to Receive Exempt Review
IRB Use Only
UAFS IRB Registration No.
E-mail to:
irb@uafs.edu
Date Rec’d:
Principle Investigator
Last Name:
First Name:
Telephone Number:
E-mail:
Click on the box to
mark.
Investigator Status:
C
1. Faculty
C
2. Staff
C
3. Undergraduate Student
C
4. Graduate Student
Faculty Advisor
Last Name:
First Name:
Department:
Office Address:
Telephone Number:
E-mail:
Project Type
C
1. Faculty Research
C
2. Staff Research
C
3. Class Project
C
4. Honors Project
C
5. Thesis/Dissertation
C
6. Other _____________________
Project Title
Brief Description of
the Project (1-2
sentences)
Brief Methods
Explanation (1-2
sentences)
One Full Literature
Citation
How the data will be
used (publication,
presentation, etc.)
Funding
Is the project receiving extramural funding:
If yes, specify source:
Please Read Carefully Before Submitting Application for Exempt Review
Applicability:
If you are requesting Exempt Status, your research activities must adhere to the following
criteria:
Present no more than minimal risk. Minimal risk means that the probability
and magnitude of harm or discomfort anticipated in the research are not greater
in and of themselves from those ordinarily encountered in daily life or during
the performance of routine physical or psychological examination or tests.
Involve only procedures listed in one or more of the Exempt Research
Categories listed below. The activities listed should not be deemed to be of
minimal risk simply because they are included on this list. Inclusion on this list
merely means that the activity is eligible for exemption when the specific
circumstances of the proposed research involve no more than minimal risk to
human subjects.
Not involve prisoners as participants.
Not be subject to FDA regulations except in accordance with 45 CFR
46.101(b)(6).
Not involve children under category 2(b) unless research involves
observations of public behavior AND the investigators do not participate in
the activities being observed.
The categories in this list apply regardless of the age of subjects, except as noted.
Please attach any surveys or interview questions you will be using.
Submit a copy of your ethics certification.
Please indicate which of the following categories applies to your research:
1. Educational Research 45CFR46.101(b)(1)
C
a. Normal Educational Practices and settings. Study of normal educational practices that will be
conducted in commonly accepted settings.
2. Research using surveys, interviews, educational testing 45CFR46.101(b)(2)
C
a. Anonymous Education Tests, Surveys, Interviews, or Observations. Involves the use of
education tests, survey procedures, interview procedures, or observations of public behavior.
May not include identifiers.
3. Research using surveys, interviews, educational testing involving elected/appointed public
officials or where confidentiality of data is protected by federal statute 45CFR46.101(b)(3)
C
a. Identifiable Subjects in Special Circumstances. If section b subjects are elected or appointed
public officials or candidates for public office or federal statutes require without exception that
the confidentiality be maintained.
4. Research using existing specimens/data 45CFR46.101(b)(4)
C
a. Collection or Study of Existing Data
5. Research or Demonstration Projects Approved by Federal Department/Agency Head
45CFR46.101(b)(5)
C
a. Public Benefit or Service Programs. Must be conducted by or subject to the approval of
department or agency head, designed to study, evaluate, or examine public benefit or service
programs, procedures, changes in or alternative under the programs, etc.
6. Taste and food quality evaluation or consumer acceptance 45CFR46.101(b)(6)
C
a. Taste and Food Evaluation and Acceptance Studies. Limited to taste and food quality
evaluation studies that do not involve risks of indigestion or vitamin deficiencies. Studies
involving consumption of alcohol, vitamins, or supplements are not eligible for exempt status.
(Bankhart & Amdur, 2006).
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