SU_NSG6101_IRB_application (2).docx - THIS IS AN EXAMPLE OF SOUTH UNIVERSITY\u2019S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN

SU_NSG6101_IRB_application (2).docx - THIS IS AN EXAMPLE OF...

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THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101 . INSTITUTIONAL REVIEW BOARD FOR THE PROTECTION OF HUMAN SUBJECTS IN RESEARCH This form is to be used for requesting IRB review for exempt, expedited and full board studies Please note that handwritten and/or incomplete forms will be returned to you. CHECKLIST FOR IRB APPLICATION SUBMISSION (to be completed by PI before submission to IRB) X Application Form with Signatures/ Confidentiality Agreements X NIH Training Certificate(s) XProtocol or Attached Research Proposal and/ or Contract/ Grant XSolicitation Announcements/Recruitment Flyers X Data Collection Instruments/Research Questions/Questionnaires/Surveys X Informed Consent Documents X Parental/Legal Guardian Permission Form (if applicable) Child Assent Form (if applicable) X Approval from Study Sites (if applicable) XMedical Screening Instrument (if applicable) X Debriefing Plan (if applicable) XStudent as Principal Investigator Worksheet (if applicable) Page 1 of 17
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THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101 . Project Title- Can the Early Implementation of Palliative Care Increase Quality of  Life PART I - INVESTIGATOR and RESEARCH PERSONNEL 1) PRINCIPAL INVESTIGATOR (Undergraduate students cannot serve as Principal Investigator, but may be listed as a Co-Investigator.) Name: Moya Talley Highest Degree Completed: Bachelors of Nursing Investigator Status: Graduate Student E-mail Address: [email protected] College/Department: Nursing Campus Mailing Address: South University, 709 Mall Boulevard,  Savannah, GA 31406 Daytime Phone: (866)848-5515 2) CO-INVESTIGATOR – 1 (if applicable) Name: Dr. Mr. Ms. Professor Highest Degree Completed: Investigator Status: Faculty Graduate Student Other Undergraduate Staff E-mail Address: College/Department: Campus Mailing Address: Daytime Phone: 3) CO-INVESTIGATOR – 2 (if applicable) Name: Dr. Mr. Ms. Professor Highest Degree Completed: Investigator Status: Faculty Graduate Student Other Undergraduate Staff E-mail Address: College/Department: Campus Mailing Address: Daytime Phone: 4) FACULTY SPONSOR (if applicable) Name: Dr. Mr. Ms. Professor Highest Degree Completed: E-mail Address: College/Department: Page 2 of 17
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THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101 . Campus Mailing Address: Daytime Phone: 5) STUDENT INVESTIGATORS/RESEARCH ASSISTANTS (if applicable) Name: E-mail: Phone: Name: Moya Talley E-mail: [email protected] ail.com Phone: 313-461-5780 Name: E-mail: Phone: Name: E-mail: Phone: Name: E-mail: Phone: PART II – FUNDING INFORMATION 1) Check all of the appropriate boxes for funding sources for this research. Include pending funding source(s).
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