K:\SPECIALS\IRB\IRB\IRB Application Revision\IRBApplication.docx IRBApplication1/6/201710/14/2018

Principia College

Institutional Research Board Approval Request Form for Research with Human Participants

To apply for IRB approval, please download and save a copy of this form using the file name [YOURLASTNAME.FIRSTNAME].1617.IRB, complete all sections, save, and email your completed form, as an attachment, to the IRB at.

You will receive a confirmation that your application has been received within one business day.

You should receive the IRB’s response within the next seven days.

Title of Research: Click here to enter text.

Brief description of your project, in everyday terms: Click here to enter text.

If this project is associated with an academic course, please give the department name, course number, and course title: Click here to enter text.

Your Name: Click here to enter text. Your email:

Are you a: ☐ Student☐ Faculty☐ Staff

If you are a student or staff, you must haveafaculty member who has agreed to act as the Lead Researcher. Please enter his/her name here: Click here to enter text.

Date research will begin: Click here to enter a date.

Expected completion date of project: Click here to enter a date.

I agree that I have read Principia College’sHuman Subjects Research Policy and that I will provide for the protection of the rights and welfare of the participants that are involved in this study as outlined in the Policy. I also agree to submit to the IRB any significant changes to the procedures of my project for IRB approval. YES ☐

  1. Have you previously submitted an application to the IRB for research on this topic?

Yes ☐ No ☐

If yes, please list the title and date of research: Click here to enter text.Click here to enter a date.

  1. This section helps the IRB understand the nature, scope, and methodology that your project entails. Please respond with a clear and specific description of your research approach:
  2. The intended outcome, decision, or action of this research is to: Click here to enter text.
  3. The location(s) of this research will be (please specify geographic location(s)): Click here to enter text.(Research conducted in countries other than the U.S. may require additional planning considerations with respect to language and/or cultural differences.)
  4. What type of data will you be collecting and how will you collect it? (e.g., surveys distributed via email to [intended recipients]; or one-on-one interviews conducted at [location] with [intended participants])
  5. Please attacha copy of your most recent draft of each script, questionnaire, or other tool(s) you will be using
  6. Describe your intended participants, including age range, and other qualitative and/or quantitative descriptors: Click here to enter text.
  7. How many participants do you hope to include in this project? Click here to enter text.
  8. I/we will select/recruit/gather participants by: Click here to enter text.
  9. I/we will☐ will not☐be offering incentives, compensation, and/or follow ups to the participants. (If offering an incentive, describe: Click here to enter text.)
  1. This section helpsthe IRB understand the degree to which respondents might be individually identifiable:
  2. Does the research involve interaction with individuals (such as through surveys, interviews, or study of previously gathered data on individuals)? Yes ☐ No ☐
  3. Can the information be identified with specific individuals, either directly (such as by an email address or name, or in a video) or indirectly (such as being associated with information such as gender or major that could, within Principia, identify or nearly identify the individual)?

Yes ☐ No ☐ Unsure ☐

  1. Are the data collected sensitive in nature, meaning that the data collected could put an individual at risk (such as a loss of job, damage to reputation, or suspension or dismissal)?

Yes ☐ No ☐ Unsure ☐

  1. Please identify the expected benefits of this research to the participants and/or to humankind in general. Principia College policy requires that risk from participation be outweighed by potential benefits.
  2. Benefits to the participants resulting from this research: Click here to enter text.
  3. Benefits to Principia College and/or humankind in general resulting from this research:Click here to enter text.
  1. Describe possible risk to participants, including possible harm to an individual(s) legally, professionally, physically, socially, psychologically, or economically. Note that all research entails some level of risk, though perhaps minimal. All efforts should be made to mitigate anticipated risk.

Possible risk(s) include: Click here to enter text.

What plans do you have in place to mitigate these risks? Click here to enter text. N/A: ☐

No foreseeable risk: ☐

  1. What is the consent process to be followed in this study? All studies must include informed consent, unless you are using existing data from a publicly available source. Please attachthe specific consent form(s) that you will use. For examples, and to review, download, and customize consent forms, visit the IRB website.
  2. Consent process: Click here to enter text.
  1. Minors and other vulnerable participants. If minors or other vulnerable participants are involved, outline the procedures you will use to obtain their agreement to participate, in addition to the consent of their authorized representative such as parent or guardian.
  2. ☐We do NOT intend to include minors or other vulnerable participants in this research. We will make every effort to exclude them from this study by Click here to enter text.
  1. We DO intend to include:

☐minors (please identify age group(s): Click here to enter text.

☐other vulnerable participants (please describe): Click here to enter text.

  1. We will use the following procedures to obtain permission by parents or guardians and for assent by children. Please describe how BOTH the adult permission and the children’s assent will be documented. (Attach the permission and assent forms): Click here to enter text.
  1. This section helps the IRB understand how you plan to ensure the confidentiality or anonymity of the information gathered in your research. While respondents cannot always remain anonymous (for example, surveys that are collected via email always are tied to an individual email address), it is the responsibility of the researcher to ensure the confidentiality of respondents.

What measures have you put in place (for example, coding of responses, location and security of data storage, names of anyone with access to data) to help ensure anonymity and/or confidentiality of respondents? For each of the stages listed below, describe your plan:

  1. While the data is being collected, we will ensure anonymity and/or confidentiality of respondents by:Click here to enter text.
  2. While the data is being used and stored, we will ensure anonymity and/or confidentiality of respondents by:Click here to enter text.
  3. When the data is being shared and/or presented, we will ensure anonymity and/or confidentiality of respondents by:Click here to enter text.
  4. After the project has been completed, we will ensure anonymity and/or confidentiality of respondents by:Click here to enter text.
  5. Alldata will be destroyed by or on this date: Click here to enter a date.
  1. Please add any additional information that you feel will be helpful for the IRB to consider when reviewing your application: Click here to enter text.
  1. If you are a student or staff member, you must ask your facultylead researcher to review and approve thiscompleted IRB application before you submit it to the IRB. Please have him/her complete the box below:


All set?

Please use this checklist to be sure you have prepared all the documents before you submit the IRB:

☐ I have read Principia College’s Human Subjects Research Policy

☐ I have answered all questions on this application

☐ (for students and staff) The faculty member designated as the Lead Researcher has read and approved/commented on my application

☐ I’ve saved the file as [YOURLASTNAME.FIRSTNAME].1617.IRB

☐ I have attached a copy of this application to the email

☐ I have attached a copy of script(s) and/or questionnaire(s)

☐ I have attached a copy of consent form(s)

Please email all documents including this application to the IRB at ;

Please also cc, as appropriate, the designated Lead Researcher

You will receive a confirmation that your application has been received within one business day.

You should receive the IRB’s response within the next seven days. Please feel free to stop in the Institutional Research office and/or call or email Roz Hibbs (x 5153) for help or questions.

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