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UNIVERSITY OF ARKANSAS FORT SMITH
Request for Review of Human Subjects Research
Request for Review of Human Subjects Research
IRB Use Only
UAFS IRB Registration No.
E-mail to: irb@uafs.edu
Principle Investigator
(if UAFS student, consult with
your professor before
submitting)
Last Name:
First Name:
Phone Number:
E-mail:
Investigator Status (click on the box to select):
Faculty
Staff
Undergraduate student
Graduate student
Faculty Advisor
Last Name:
First Name:
Department:
Office Address:
Phone Number:
E-mail:
Project Type
(click on the box to select)
Faculty research
Staff research
Class project
Honors project
Thesis/Dissertation
Other (Please specify)
Project Title
Funding
Is the project receiving extramural funding? If yes, specify source.
Yes No
Number of
participants
_____ Children under 18
_____ UA Fort Smith students (18 and over)
_____ Adult non-students
_____ Other (Identify and specify no. needed)
Dates of contact with
participants
Date of first contact:
Date of last contact:
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Request for Review of Human Subjects Research
Informed consent
procedures
Forms to include:
Signed consent form(s)
Other method (e.g., implied consent or assent, attach explanation)
Not applicable to this study, attach explanation
Confidentiality of data
Explain how the Researcher will maintain confidentiality.
Risks or Benefits
Will participants be exposed to more than minimal risk? Attach a description
of any risks or discomforts associated with the study and the precautions to
minimize them.
Yes No
Check all that apply
A. Deception of or withholding information from participants. Justify
use of the practice.
B. Medical clearance necessary prior to participation
C. Samples (blood, tissue, etc.) from participant
D. Administration of substances (food, medicine, etc.) to the
participants
E. Physical exercise or conditioning for subjects
F. Research involving children
G. Research involving pregnant women or fetuses
H. Research involving participants of institutions
I. Research involving IRB at another institution
J. Research requiring approval from another institution
(B, C, D, and E require
an explanation of
procedures and safety
precautions.)
(F, G, and H require an
explanation of informed
consent procedures)
(I and J require letters of
approval from agencies)
Checklist for
completion
IRB application
Brief review of the literature
Full description of the project (include how collected data will be
used)
Methodology (methods to be used) See details below.
Ethics certification (If initial application to UA Fort Smith IRB or
Cert # if not first time) (Appendix A)
Letter to participants, script of oral protocols to read to participants, etc.
(Appendix B)
Letter of approval from cooperating institutions and/or other IRB
approvals as applicable (Appendix C)
Copies of the data collection instruments (Appendix D)
Informed consent form(s) (Appendix E)
Debriefing form(s) (Appendix F)
References with complete citations
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Instructions: In accordance with Federal Regulations, the UAFS IRB must approve your
research proposal before you collect data. If you are from an outside institution, you must
obtain approval from the Office of the Provost and Senior Vice Chancellor before submitting to
the IRB. Please complete the following sections carefully, clearly, and concisely as this will
minimize review time and quicken our response to you.
Brief Review of the Literature (200 words exclusive of references)
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Full Description of the Project (In space provided, enter a full description of the study. What is
the nature of this proposed project? What is your research question? What is its significance?
What is/are your hypothesis(es)? What is/are your expected outcome(s)?) Who will this
information be shared with? How will the data be shared?
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Methodology (Describe whom you plan to recruit as participants, a description of the
materials, equipment, or instruments you plan to use to collect your data.)
Participants (Anticipated demographics)
Materials, Equipment, Instruments (Thoroughly describe. Place a copy of your proposed
instrument(s) in Appendix D.)
Procedures (Describe exactly how you plan to recruit your participants. What script will you use
to recruit them? How will you seek consent? What letters of approval will be needed? Describe
exactly how you plan to collect data (i.e., what will the participants engage in to complete your
study?).
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LIST OF APPENDICES
APPENDIX A Ethics Certification
APPENDIX B Letters to Participants, Scripts
APPENDIX C Letter(s) of Approval from Other Institutions / IRB Approvals
APPENDIX D Instrument(s)
APPENDIX E Informed Consent Form(s)
APPENDIX F Debriefing Form(s)
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APPENDIX A
Ethics Certification
If this is your initial application to the UAFS IRB Committee, you (and your faculty
advisor/professor) need to submit a copy of the ethics certification in Appendix A. As a student,
you can earn certification through UAFS IRB online certification course. (Your professor will
contact the Institutional Support to add your name to the Blackboard Certification course.) This
certification takes about two hours to complete. The online course allows you to complete the
certification as time allows.
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APPENDIX B
Letters to Participants, Scripts
Provide a copy of the letters, flyers, etc., that you plan to use to recruit your participants or any
literature you intend to use to communicate with you participants about your study. For example,
if you intend to recruit via flyers on campus, provide an exact copy of what you would like to use
and the associated UAFS Student Activities form.
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APPENDIX C
Letter(s) of Approval from other Institutions / IRB Approvals
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APPENDIX D
Instrument(s)
If you are planning to use a published instrument or if you plan to modify (to any degree) a
published instrument, please be sure to cite the reference here and include the compete citation in
your list of references. The instrument you place here is to be the exact one you plan to present to
your participants.
If the UAFS IRB approves this proposal, any changes to it should be reviewed by the IRB.
The IRB will respond within 48 hours.
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APPENDIX E
Submit only the Informed Consent you will use for the research project. Be sure to delete the ones
that are samples. Be sure to complete the form using your information.
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APPENDIX E
Informed Consent Form
Sample 1
Name of Institution:
Department:
Title of the Research Project:
Purpose of the Study:
The purpose of the Gender Differences in Mate Selection after First Marriage is to better
understand the degree to which career, money, and spiritually play a significant role and to
measure socially maturity.
Procedures:
Confidentiality/Safeguards:
Risks:
Benefits:
Right to Withdraw:
Contact Information:
A copy of this form is yours to keep.
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PARTICIPANT COPY
Participation Consent Form
You are making the decision whether or not to participate in the _________________________
study. Your signature indicates that you have read and understood the information provided and
have decided to participate in the study.
I am willing to participate in this study, and verify that I am 18 years of age or older.
Participant’s Name (Printed)
Participant’s Signature Date
Witness (Researcher) (Printed)
Witness (Researcher) Signature Date
OFFICE COPY
Participation Consent Form
You are making the decision whether or not to participate in the _________________________
study. Your signature indicates that you have read and understood the information provided and
have decided to participate in the study.
I am willing to participate in this study, and verify that I am 18 years of age or older.
Printed Name of Participant
Participant’s Signature Date
Printed Name of Witness (Researcher)
Witness (Researcher) Signature Date
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APPENDIX E
Informed Consent Form
Sample 2
This sample is adopted from the following Website:
https://rcr.gradsch.wisc.edu/cfwizard/start.asp?wisc#
UNIVERSITY OF ARKANSAS - FORT SMITH
Research Participant Information and Consent Form
Title of the Study:
Principal Investigator:
Student Researcher: Student name at 479.788.0000 or student@uafortsmtih.edu
Description of the Research:
You are invited to participate in a research study about the way you study and learn. You have
been asked to participate because we are interested in how college students study and learn. The
purpose of the research is to gain an understanding of how college students study and learn. It is
also an assignment in **** course this Fall 2009 semester. This study will include male and
female college students here at UA Fort Smith. Data for this research study will be collected on
UA Fort Smith's campus.
What will my participation involve?
If you decide to participate in this research, you will be asked to complete a five-minute survey
containing true and false items. Your participation will last approximately five-minute and will
require only one session.
Are there any risks to me?
There are no risks associated with this research study.
Are there any benefits to me?
The benefit of your participation will be the satisfaction of knowing that you have helped a
colleague with a required assignment in a required course. Thank you!
How will my confidentiality be protected?
This study is anonymous. Neither your name nor any other identifiable information is recorded.
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Whom should I contact if I have questions?
You may ask any questions about the research at any time. If you have questions about the
research after you leave today, you should contact the Principal Investigator,
at .
If you are not satisfied with response of research team, have more questions, or want to talk with
someone about your rights as a research participant, you should contact the IRB Office at
479.788.0000. Your participation is voluntary. If you decide not to participate or to withdraw
from the study, it will have no effect on your grade in this class. Your signature indicates that
you have read this consent form, had an opportunity to ask any questions about your participation
in this research, and voluntarily consent to participate. You will receive a copy of this form for
your records.
See attached signature pages.
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PARTICIPANT COPY
Participation Consent Form
You are making the decision whether or not to participate in the _________________________
study. Your signature indicates that you have read and understood the information provided and
have decided to participate in the study.
I am willing to participate in this study, and verify that I am 18 years of age or older.
Printed Name of Participant
Participant’s Signature Date
Printed Name of Witness (Researcher)
Witness (Researcher) Signature Date
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OFFICE COPY
Participation Consent Form
You are making the decision whether or not to participate in the _________________________
study. Your signature indicates that you have read and understood the information provided and
have decided to participate in the study.
I am willing to participate in this study, and verify that I am 18 years of age or older.
Printed Name of Participant
Participant’s Signature Date
Printed Name of Witness (Researcher)
Witness (Researcher) Signature Date
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APPENDIX F
Debriefing Form Sample
Thank you for participating in this study. Please read all of the following information.
The purpose of the study is
Please remember that your individual responses will remain anonymous and that the data will be
examined on a grouped basis only. Your informed consent form, which contains your name, will
be kept separate from the answers that you gave on the questionnaires. The student investigator
to whom you have given your responses will deliver all consent forms to the Principal Investigator
for this study (Dr. John/Suzie Q. Public, Department of Services) who will keep all consent forms
in a locked file to which only he or she will have access.
If you have any questions about this study, if you should experience any negative feelings as a
result of participating in this study or if you are interested in knowing the results of this study,
please contact Dr. John/Suzie Q. Public, Department of Services at State University (phone:
479.788.0000). If you should have any concerns that Dr. John/Suzie Q. Public is not able to
address, you may also contact the State University Counseling Center located on the 3
rd
floor of
the Pendergraft Bldg., (phone: 479.788.0000)
Again, your cooperation and participation are greatly appreciated.
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REFERENCES
All citations noted anywhere in this application must be presented here in full citation format.
Alphabetize by the last name of the first author. Please include page numbers. If you plan to use
a published instrument (or a modified one), place the complete citation here and make note of it
in Appendix D where you placed this instrument.
Citation examples:
Feingold, A. (1992). Gender differences in mate selection preferences: A test of the parental
investment model. Psychological Bulletin, 112(1), 125-139.
Wood, D., Brumbaugh, C. C. (2009). Using revealed mate preferences to evaluate market force and
differential preference explanations for mate selection. Journal of Personality and Social
Psychology, 96, 1226-1244.
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