irbform2 - Institutional Review Board for the Protection of...

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Institutional Review Board for the Protection of Human Subjects Research UNDERGRADUATE Research Qualifying for Exemption from Federal Regulations (Based on the Code of Federal Regulations, Title 45, Part 46.101.and Valdosta State University Policy on Research and Human Subjects) University procedures provide for review of research involving human subjects that may be exempt under federal, state, and university regulations. The exempt categories and exceptions are described on the reverse of this form. Research by undergraduates as part of class activities, if all questions below can be answered “NO” will be accepted as “Exempt.” A “YES” response means IRB must review. Completion of this form, signed by the student and the instructor for the class and submitted with a completed Application for Review will be accepted as Exempt and will require no further review or action. Such research will not receive a particular research number but will be filed under the class number and semester as a method of locating. Questions may be directed to any IRB member. Student Researcher ____________________________________________ Class Name/Number Instructor Name _______________________________________________ Department _____________________________ College Instructor Phone Number: Instructor’s E-mail Research Title Semester research will be accomplished (i.e. Fall, 2005) I. CATEGORY: (categories are described on reverse side) Please circle most appropriate number: 1 2 3 4 5 6 II. ABSTRACT: Provide a brief description of your research, the participants, and how confidentiality will be maintained. Keep to 50 words or less. III. Human Subjects (to be considered ‘exempt’ all of these responses must be answered “NO”): YES NO Are any subjects presumed to be not legally competent? R R Are any subjects under 18 years of age? Are any subjects confined in a correctional or detention facility? R R Is pregnancy a prerequisite for serving as a subject? R R Are fetuses in utero subjects in this research? R R Are personal records (medical, academic, etc.) used without written consent? R R Are data from subjects (responses, information, specimens) directly or indirectly identifiable? R R Are data damaging to subjects’ financial standing, employability or reputation? R R Is material obtained by autopsy used in the research? R R By my signature below I attest that I am an undergraduate student and that the responses are true to the best of my knowledge.
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