Student/Classroom Research Projects(S) Form

INSTITUTIONAL REVIEW BOARD (IRB) APPLICATION

Student/Classroom Research Projects(s) Form

Use this form for any individual student research project involving human subjects (independent study, capstone, thesis, etc.).

INSTITUTIONAL REVIEW BOARD APPLICATION

Form Continued

Please complete the following sections in enough detail for the IRB to understand the nature, intent and procedure of you project. Please type the following information within this document.

1. Title:

2. Project Summary: Summarize your project in enough detail to give the IRB an overview of the project:

3. Research Question: State your research questions and hypothesis if applicable:

4. Sample: Please describe your data source including where you are procuring your sample. Include the target sample demographics, inducement to obtain sample, recruiting materials, inclusion and exclusion criteria, and any other pertinent data.

5. Procedure: Describe all applicable research procedures. Please list a) recruitment procedures, b) randomization procedures, c) research design and data collection procedures, d) description of treatment and control conditions, e) qualitative methodology. Please include all instructions given to participants at all phases of the research.

6. Data Collection Instruments: Please list all instruments and provide a copy of all measures, surveys and instrumentation:

7. Privacy and Confidentiality: Explain how you will safeguard the participant’s privacy and confidentiality:

8. Foreseeable Risks: What are the risks associated with this project and what will you do to minimize the risk?

9. Informed Consent: Please indicate the procedures for obtaining consent from the agency that provides access to participants (if applicable) and from participants and/or their legally responsible representative.

If applicable:

• If the agency is other than WJU, attach a letter of agreement from the responsible agency to the IRB application. If informed consent is for research that involves minors, address the parent or guardian using language such as “your child…”
• If the research involves minors ages 12-17, include a Student Assent form in addition to the Informed Consent form.
• If research is conducted exclusively through the use of self report questionnaires or opinion surveys, include an Informed Consent for Electronic Survey Questionnaires.
• If clinical research involves human subjects, the following additional forms must be signed by the participant: California Experimental Subjects Bill of Rights, and Use of Private Health Information.

10. Data Analysis: Please include your strategy for data analysis:

11. Dissemination: Please describe your plan for dissemination of your data including targeted conferences and publications:

12. Explanation of reason for exempt or expedited status (if applicable):

Informed Consent: Please sign at the bottom indicating that you have included the following items (as applicable) to your informed consent. Please include your informed consent with the IRB application.

When using humans as research subjects you must first obtain their informed consent. Use this checklist to effectively create an informed consent form.

1. a) A statement explaining the purpose of the research.

b) A statement of the expected duration of the subject’s participation.

c) A description of the procedures to be followed.

2.A description of any reasonable foreseeable risks or discomforts to the subject, including invasion of privacy.

3.A description of any benefits reasonably expected from the research, either to the subject or to others.

4.A disclosure of appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the subject.

5.A statement informing the subject about how his/her confidentiality will be guarded; i.e. that their confidentiality will be protected by assigned code numbers, by limitations of who has access to data, by data storage in locked cabinets, by locked computer files, etc.

6.If research involves more than a minimal risk, explain whether any compensation or medical treatment is available if injury occurs and, if so, what they consist of, or where further information may be obtained.

7. The name, address, and telephone number of the principal investigator of the research project, and his/her affiliation with William Jessup University. If the principal investigator is a student, the name and telephone number of the faculty advisor is also required.

8.A statement that the subject’s participation is voluntary, and that his/her refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitle, and that the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitle.

9. a) If written informed is required, a place for the subject to sign and date the form must be included. A statement that a copy of the signed consent form will be given to the subject for his/her records must also be included.

10. A statement informing the subject that inquiries regarding the nature of the research, his/her rights as a subject, or any other aspect of the research as it relates to his/her participation as a subject can be directed to the Office of Academic Research: Dr. Aisha N. Lowe, Director (; 916-577-2258).

11. If clinical research involves human subjects:

A signed California Experimental Subjects Bill of Rights and

A signed authorization for Use of Private Health Information is required.

Signed:______

Signatures:

Assurance. The undersigned have reviewed the standards for exempt, expedited, and full review by the IRB and attached the complete project description required.

Signatures

Student ______Date ______

(if more than one attach with list of names and ID numbers and signatures)

Faculty______Date______

Department Chair______Date______

Submit two complete hard copies and an electronic copy to the Office of the Provost.

For IRB Use Only

[ ] Preliminary approval (e.g. grant proposal, institutional research, including CFR 46.118). Re-submission required prior to data collection.

[ ] Approved as exempt. No further review needed unless protocol changes.

Signature: Certified Faculty______Date______

OR

Signature: IRB Chair or Designee______Date______

[ ] Approved as expedited. No further review needed unless the protocol changes or data-gathering extends beyond time limit.

Project approval expires______

Signature: IRB Chair or Designee______Date ______

[ ] Full Review

[ ] Approved as submitted.

Project approval expires______

[ ] Not approved (see attachment). Re-submission is required.

Signature: IRB Chair______Date______

Names of board members who reviewed this project:

______

______