APPLICATION FOR CONDUCTING RESEARCH WITH HUMAN SUBJECTS

CALIFORNIA STATE UNIVERSITY, FRESNO

Instructions: This form is to be completed by those conducting research with human subjects. Please review the Policy and Procedures for Research with Human Subjects at California State University, Fresno, (in the Student Corner on the Doctoral Program webpage) to help you define the category of exemption for which you are applying.

Application Category (please check the appropriate category in which your research falls)

a.  ☐Exempt (complete Section I and Section II)

b.  ☐Minimal Risk (complete Section I and Section III)

c.  ☐ At Risk (complete Section I and Section III.) Research in this category will also need to be

reviewed by the University Board on the Protection of Human Subjects

Please attach the following materials to your application and check the boxes to indicate they are attached.

1.  ☐Copy of Chapter 3

2.  ☐Copy of Survey or Research Instrument

3.  ☐Copy of Informed Consent

4.  ☐Appropriate signature from Dissertation Chair

Note: Incomplete applications will not be processed. Incomplete forms will be returned for the required information. No data collection involving human subjects may take place until the proposal has been approved by all required reviewers.

Section I.

Complete all sections. If a section is not applicable, indicate with N/A

Student Information
Name:
Student ID:
Phone:
Title of Study:
Principal Investigator
Name:
Department:
Mail Stop:
Phone:

1.

DPELFS Form 5

APPLICATION FOR CONDUCTING RESEARCH WITH HUMAN SUBJECTS

Section II.

Exempt: If you believe that your research project is exempt from full review by the Committee on the Protection of Human Subjects. Please complete this section.

Student’s Statement of Exemption

In my judgment, my proposed research involving human subjects is exempt from consideration. The following section(s) of the CSUF “Policies and Procedures for Research with Human Subjects” apply to my research and to my statement:

_____3.5.2A _____3.5.2C _____3.5.2E

_____3.5.2B _____3.5.2D _____3.5.2F

Statement of Basis for Exemption:

Student Signature Date

Expires one year from above date.

Principal Investigator Signature Date

Human Subjects Research Exemption Reviewer Response:

1) I hereby verify that your proposed research is exempt from further Human Subjects review.

______2) This research appears not to be in one of the exempt categories. Your proposal is being forwarded for review by 3 department faculty.

DPELFS Director or Designee Signature Date

APPLICATION FOR CONDUCTING RESEARCH WITH HUMAN SUBJECTS

Section III.

Minimal Risk and At Risk Research: A departmental review by at least three faculty who are not involved in the research under consideration is required for research that does not meet exempt status. Each faculty reviewer should indicate whether they believe the research is Minimal Risk or At Risk.

Name / Level of Risk / Signature
Principal Investigator: / ☐At Risk
☐Minimal Risk / ______
PI Signature
Reviewer: / ☐At Risk
☐Minimal Risk / Approve:
Disapproved:
Comments:
Reviewer: / ☐At Risk
☐Minimal Risk / Approve:
Disapproved:
Comments:
Reviewer: / ☐At Risk
☐Minimal Risk / Approve:
Disapproved:
Comments:

Principal Investigator notified of HS approval on (date) by (name)

3.