SU_NSG6101_IRB_application.doc - THIS IS AN EXAMPLE OF SOUTH UNIVERSITY\u2019S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT

SU_NSG6101_IRB_application.doc - 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) Application Form with Signatures/ Confidentiality Agreements NIH Training Certificate(s) Protocol or Attached Research Proposal and/ or Contract/ Grant Solicitation Announcements/Recruitment Flyers Data Collection Instruments/Research Questions/Questionnaires/Surveys Informed Consent Documents Parental/Legal Guardian Permission Form (if applicable) Child Assent Form (if applicable) Approval from Study Sites (if applicable) Medical Screening Instrument (if applicable) Debriefing Plan (if applicable) Student as Principal Investigator Worksheet (if applicable) Page 1 of 18
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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 Mental Health Illness Among Adolescents 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: Jorge Hernandez Dr. Mr. Ms. Professor Highest Degree Completed: APRN Investigator Status: Faculty Graduate Student Staff E-mail Address: [email protected] College/Department: South University Campus Mailing Address: [email protected] Daytime Phone: (832)614-1860 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: Campus Mailing Address: Daytime Phone: 5) STUDENT INVESTIGATORS/RESEARCH ASSISTANTS (if applicable) Page 2 of 18
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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 . Name: E-mail: Phone: Name: E-mail: Phone: 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). Extramural College Department Other: P.I. of Grant or Contract: Sponsor: Contract/Grant No.
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