Project #:
(IRB use only)
Version June 2017
REQUEST FOR APPROVAL TO CONDUCT RESEARCH INVOLVING HUMAN PARTICIPANTS AT SMITH COLLEGE THAT HAS BEEN APPROVED BY ANOTHER INSTITUTION
Please provide the following information for the protocol as approved bytheinstitution that is providing IRB oversight (Primary Institution/IRB).Name of institution:
Protocol Title
Protocol Number:
Principal Investigator(s) at Primary Institution:
Name: / Affiliation:
Phone: / Email:
Name: / Affiliation:
Phone: / Email:
Approval date:
Review status for approval to perform research under the oversight of the Primary IRB:
Exempt / Expedited / Full
Please provide the following information for approval to conduct the research at Smith
Date research is to begin at Smith:
Anticipated data collection end date:
Anticipated data analysis end date:
Principal Investigator(s):
Name: / Dept.:
Phone: / Email:
Name: / Dept.:
Phone: / Email:
Faculty Adviser (required for all student research):
Name: / Dept.:
Phone: / Email:
Person performing the work if different than above:
Name: / Dept.:
Phone: / Email:
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 participants involved. I acknowledge my responsibility as an investigator to secure the informed consent of the participants 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 Smith College policies, which govern research involving human subjects. Any deviation from the project (e.g., change in principal investigator, research methodology, subject recruitment procedures, etc.) must be approved by the primary IRB, and signed proof of approval of changes must be submitted to Smith College IRB prior to implementation. The P.I. agrees to report all protocol deviations or adverse events IMMEDIATELY to the Smith College IRB.
Principal Investigator(s):
Name: / Signature:
Date:
The Faculty Adviser's signature on the Research Proposal confirms that they have supervised the composition of the proposal and they approve of the research proposal as submitted.
Faculty Adviser:
Name: / Signature:
Date:
Please submit this form to the Smith College IRB with the following documents:
-signed proof of approval by the primary IRB
-a copy of the approved proposal and consent form(s)
-a copy of the consent form(s) that will be used at Smith (if different from original consent forms)
-any and all supporting documents (recruitment tools, survey instruments, etc.)
You may be asked to provide other documentation, as needed.
(For Committee Use)
Review status for approval to perform research at Smith:
Exempt / Expedited / Full
Not Approved
This proposal for the use of human participants has been reviewed and approved by Smith College Institutional Review Board.
Chair, Smith College IRB
Name: / Signature:
Date: