West Virginia Wesleyan College
Institutional Research Review Board
Application for Study
1. Title of Project:
2. Investi
gator(s) Name(s):
Principal Investigator’s Na
me:
PI’s
B
ox #:
PI's
E-Mail:
PI’s
P
hone #: PI's School/Department:
Co-Investigator’s Name:
CO’s Box #: CO's E-Mail:
CO’s Phone #: CO's School/Department:
Co-Investigator’s Name:
CO’s Box #: CO's E-Mail:
CO’s Phone #: CO's School/Department:
Co-Investigator’s Name:
CO’s Box #: CO's E-Mail:
CO’s Phone #: CO's School/Department:
4. Type of review requested:
Exempt
Expedited
Full Board
Request for renewal of previously-approved project
5. This research involves (check all that apply):
Collection or study of existing, data, documents, records or specimens, recorded
without identifiers
Normal education practices conducted in the established or commonly accepted
educational settings
Educational tests (cognitive diagnostic, aptitude or achievement)
Observation of public behavior
Surveys, interviews or hand-out for subjects over 18
Mail/Email
Telephone
Face-to-face
Only surveys or interviews of elected, appointed or other public officials
Audiotaping/videotaping (Specify:
Food tasting and evaluation
Research and demonstration projects
Special populations (pregnant females, prisoners, wards of the state, adults with
impa
ired decision-making capacity)
3. Proposed start date:
Proposed end date:
Project #:
For IRRB Use Only
WVWC IRRB Application for Study, page 2
6. Reason for conducting the research (describe in provided space AND check all that apply):
Description:
Professional scholarly activity
Undergraduate class assignment
Graduate class assignment
Academic department requirement
Other (Please specify:
7. A. Explanation of procedures involved (please continue on additional page if needed):
B. Explanation of identification and selection of subjects (please continue on additional page needed):
8. Explanation of known risks to human subjects (please continue on additional page if needed):
10. Please indicate any and all documents you are including in your submission (attach electronic copies to email
submission and hard copies to your submission packet):
Informed consent
Cover letter
Written (
including web-based)
/spoken directions
Questionnaire/Interview protocol/Coding sheet
Permission
from external institution on their letterhead
11. Description of source of funding for study (please continue on additional page if needed):
12. Signatures of applicants and related parties:
______________________________________________
Principal Investigator/Faculty Advisor Date
______________________________________________
Co-Investigator Date
______________________________________________
Co-Investigator Date
______________________________________________
Co-Investigator Date
9. A. Explanation of how records will be kept and disposed of (please continue on additional page if needed):
B. Explanation of how and where results will be used and reported (please continue on additional page if needed):
Date Received:
Project #:
IRRB Committee Assignment:
Date Approved:
For Use By IRRB Committee Only
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