Request for Review of Human Subjects Research
☐ Signed consent form(s)
☐ Other method (e.g., implied consent or assent, attach explanation)
☐ Not applicable to this study, attach explanation
Explain how the Researcher will maintain confidentiality.
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
☐ Yes ☐ No
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
☐ 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
(I and J require letters of
☐ Brief review of the literature
☐ Full description of the project (include how collected data will be
☐ 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.
☐ 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