COMMITTEE ON HUMAN RESEARCH

Notification form for the previously approved, ongoing research with human subjects.

Part 1- Administrative Information

1. Project Title

2. Contact Information

2.1. Principal Investigator (PI)

Name
College/Division
Department/Unit
Home Phone
Work Phone
E-Mail Address

Status

Undergraduate Student*Post Doctoral Fellow*Staff

Graduate Student*FacultyOther (Specify)

* Faculty member supervising the project:

E-mail address:

2.2. Co-PIs and members of the Research team

Name / E-Mail Address / College/Division / Department/Unit / City/Country

3. Funding information

3.1. Is this research being funded by an External Funding Agency?

No

Yes

3.1.1. External funding

Name of funding agency:

Grant No:

Part 2- Study design, methods and procedures

1. Type of project/study:

Please select ALL of the categories of work that apply to this proposed project.

Active collection of data (not human biological materials or biomedical data**)

Active collection of human biological materials orbiomedical data)

Use of existing data (not human biological materials)

Use of existing human biological materials

**includes biological, clinical, medical data or anthropomorphic data

2. Please provide a lay summary of the study, including the purpose and the research questions and hypothesis to be evaluated in non-technical language.Provide supporting background information from prior studies that will support this study.

Please attach a copy of the consent form, surveys, questionnaire etc. that you are currently using for your project.

Part 3- Additional Information

3.1 Is this research being approved by an IRB?

No

Yes

Name of IRB

Approval date/number:

Please attach a copy of the IRB approval letter.

3.2 Project Start Date or Estimated Project Start Date:

Scheduled Finish Date:

Estimated Project Duration:

Signature(s)

This page is to be signed by the Principal Investigator. If the investigator is an undergraduate, graduatestudent, or doctoral student, the faculty supervisor must also sign in the lower box.

Investigator

I certify that the information I provide in this application is correct and complete. I also pledge that

I will not change any of the procedures, forms, or protocols used in this study without first seeking review and approval from the Institutional Review Board.

______

Signature of Investigator Date

Faculty Supervisor

“I have examined this completed form and I am satisfied with the adequacy of the proposed research design and the measures proposed for the protection of the research participants. I will take responsibility for providing supervision of the student; for informing him/her of the need for the safekeeping of all raw data (e.g., surveys, questionnaires, interview notes, video/audio recordings, test protocols, etc.), as well as signed consent forms, in a University office or computer file; and for overseeing all compliance with the IRB’s policies and procedures.”

______

Signature of Faculty SupervisorDate

Contact Information of Faculty Supervisor: ______

Submit one electronic copy of all the required documents to

For Official Use Only

Protocol #:
Initial Protocol #: (If Application is a renewal or revision)
Exemption #: (If approved by CHR Chair below.) / Type of Review Recommended
Full IRB Review
Expedited Review
Exemption
Utilizing expedited review procedures, I have reviewed the Human Subjects Protocol Application attached and all appended documentation and have determined that this research protocol is exempt from full CHR Review.
Signature:______
IRB Chair