Request for Approval to Conduct Research

Texas Dept. of Family Form K-907-2704

and Protective Services August 2013

Request for Approval to Conduct Research

The purpose of this form is to request approval from the Child Protective Services (CPS) Division of the Texas Department of Family and Protective Services (DFPS) to conduct research.

Submit this form and supporting documents (e.g., IRB Application and Approval; Study Instruments; Surveys; Consent Forms) to DFPS at . If the request is approved, DFPS will contact the Requester to initiate a Memorandum of Understanding (MOU) and request the appropriate Confidentiality Statement, Volunteer Application forms, and Background Check Authorization, if applicable.

1.  Organization/University, if applicable:
2.  Name of Requester: Title:
Telephone Number: e-mail Address:
3.  External Collaborators, if applicable:
4.  Research Purpose, including Research Question and Importance (Please attach additional sheets, if necessary.):
5.  Description of Research Design and Analysis Plan (Attach additional sheets, if necessary.):
6.  Research Time Frame - Begin Date: End Date:
7.  Description of Support Requested from DFPS, including Specific Data Needs, Staff Resources, etc. (Attach additional sheets, if necessary.):
8.  Location (e.g., Travis County; City of Dallas; Region 01; Statewide):
9.  If research results will be published, please specify (e.g., Title of Journal):
10.  DFPS requires review of research results prior to publication. Do you agree to provide DFPS with ample time to review and provide feedback prior to publication?
11.  Is Institutional Review Board (IRB) approval required for this study?
If yes, date of IRB review:
FOR USE BY DFPS:
Approver Name / Approval Date
CPS Regional Director(s):
CPS S.O. Director(s):
Management Reporting and Statistics:
General Counsel:
Government Relations:
CPS Assistant Commissioner:
Other (please specify):
DFPS Comments:
DFPS Commissioner:

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