SU_NSG6101_IRB_application.doc - THIS IS AN EXAMPLE OF...

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

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: [phone]
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

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.