IRBSample3600

IRBSample3600 - Valdosta State University APPLICATION FOR...

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Institutional Review Board (IRB) Revised: 9.27.2007 Valdosta State University Page 1 of 7 Valdosta State University APPLICATION FOR USE OF HUMAN PARTICIPANTS IN RESEARCH INSTRUCTIONS: Complete this form by checking FOR IRB USE ONLY: IRB - __________ - _______ appropriate boxes, answering applicable questions, Received: _____________ Reviewed: _______________ attaching required documents, and signing the certification. Exemption: Yes No Category(ies): ____________ Submit package to the Office of Grants & Contracts. Reviewer Signature: _____________________________ ( NOTE: Incomplete applications will be returned unreviewed.) Expedited: Yes No Category(ies): ____________ PLEASE RETAIN FORMAT ON ALL SEVEN PAGES Project Title: _________________________________________________________________________________________ Responsible Researcher: _________________________ Project Dates: From ___/___/___ To: ___/___/___ MM DD YY MM DD YY Department: ____________________________________ Minimum # of Participants (including controls): ______ Maximum # of Participants (including controls): ______ E-mail: ________________ Telephone: _____________ External Funding: Yes No Mailing Address (if Student): If YES, Sponsor: ________________________________ _____ __________________________________________ _______________________________________________ (Note: If the research is or will be externally funded, include a copy of the portion of the proposal or award that describes the use of human participants with your application.) VSU Status: General Faculty Adjunct Faculty Research Associate Administrator/Staff Member Graduate Student Undergraduate Student Other: _____________________ If you are a VSU student, please indicate the academic purpose of the proposed research: Doctoral Dissertation Master’s Thesis Undergraduate/Honors Senior Project Other: ___________________________________ (Note: If your research is subject to oversight by another institution’s IRB (i.e., the research is intended to satisfy degree requirements at another institution), please consult with the IRB Administrator by calling 229-259-5045. Co-Investigator Name(s) Institutional Affiliation * E-mail Address IRB FWA Number ________________________ __________________________ ________________________ _________________ ________________________ __________________________ ________________________ _________________ * If not affiliated with Valdosta State University. If any Co-Investigator is not affiliated with an institution that has a federally-assured IRB, he/she will be required to complete IRB training and execute an “Unaffiliated Investigator Agreement” with the VSU IRB. Applicability of IRB Oversight of Student-Conducted Projects: Most student-conducted class assignments that involve observing, surveying, interviewing, or otherwise interacting with other individuals do not constitute “research” as defined by the VSU IRB and are not are not subject to IRB oversight. Specifically, the following types of student
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IRBSample3600 - Valdosta State University APPLICATION FOR...

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