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
