Arkansas State University Institutional Review Board

ARKANSAS STATE UNIVERSITY INSTITUTIONAL REVIEW BOARD

for the PROTECTION OF HUMAN SUBJECTS (IRB)

DOCUMENTATION OF REVIEW AND APPROVAL

of Exempt Research Projects Utilizing Human Subjects

TITLE OF PROJECT

PROJECT DURATION - START DATE END DATE

PRIN. INVESTIGATOR SCHOOL/DEPARTMENT

MAILING ADDRESS TELEPHONE

RANK:Faculty Staff Student Other (specify)

If rank is other than faculty, name of faculty adviser/sponsor

CAMPUS BUILDING/ROOM # TELEPHONE

FUNDED PROJECT # New Continuation

As the signature below testifies, the principal investigator is pledged to conform to the following:

As one engaged in investigation utilizing human subjects, I acknowledge the rights and welfare of the human subject involved.

I acknowledge my responsibility as an investigator to secure the informed consent of the subject by explaining the procedures, in so far as possible, and by describing the risks as weighed against the potential benefits of the investigation.

I assure the Committee that all procedures performed under the project will be conducted in accordance with those Federal regulations and University policies which govern research involving human subjects. Any substantive deviation from the project, (e.g., change in principal investigator, research methodology, subject recruitment procedures, etc.) will be submitted to the Committee in the form of an amendment for its approval prior to implementation.

PRINCIPAL INVESTIGATOR:

(typed name) (signature) (date)

FACULTY ADVISER/SPONSOR:

(typed name) (signature) (date)

CAMPUS LEVEL REVIEW

This protocol for the use of human subjects has been reviewed and approved by the Arkansas State University Committee for the Protection of Human Subjects.

Exempt Review # Not Approved

Chair/Agent IRB Committee Date

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logged in approval logged copy to PI copy to OOR copy to dept.

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EXEMPT RESEARCH ATTACHMENT

Use type size no smaller than 10 point.

A. Please specify the exemption category(ies) that applies to this research (from page ii or iii, items 1-6).

B. Provide a brief description of the purpose of the proposed study and the procedures to be used.

C. Explain how subjects will be selected, how many will be involved, and any benefits to the subjects.

D. Where will this study be conducted?

E. How much time will be required of the subjects?

F. If using questionnaires, how will they be distributed and collected?

G. Please list all primary investigators here, along with their primary position (or title), and include their signatures.

Name (please type)Position or Title Signature

H. Informed Consent. Please see instructions for guidelines on informed consent. Include here or attach (on a separate sheet) the informed consent statement or information sheet that you will be using. If you are using an information sheet, please be sure to indicate whether it take an oral or written form.

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I. Please provide a copy of research materials (e.g., surveys, interview questions) as one or more attachments or Appendixes.

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