Research Request Form
For questions regarding this form, please contact Dr. Tracy Walker at tracy.walker@coderva.org.
Today's Date
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Today's date
Name
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First Name
Last Name
Email address
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email address
Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Job Title
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Job Title
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Title of Project
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Title
Why are you conducting this research?
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Independent Research
Masters Thesis
University Class Requirements
Dissertation Research
Select one option from the dropdown menu
University or School Affiliation (if any) - Use N/A if no affiliation
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Affiliation
Time frame in which you are requesting to conduct your study:
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Approximate Dates
Will this study be reviewed and approved by an Institutional Review Board (IRB)?
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I will initiate IRB review and approval after receiving feedback from CodeRVA. (Evidence of IRB review must be received prior to initiating the study).
IRB review is pending. (Evidence of IRB review must be received prior to initiating the study).
IRB has fully reviewed and approved my study. (Evidence of IRB review must be received prior to initiating the study).
This study is exempt from IRB approval.
If you indicated that this study is exempt from IRB approval, please explain why:
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Which population are you interested in including in your study? Check all that apply.
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9th graders
10th graders
11th graders
12th graders
CodeRVA Graduates
Staff
Other
Is there a specific content area you are interested in studying? Check all that apply.
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Humanities (English and history)
Math
Science
Computer Science
All content areas would be included
Student Services (Counselors and/or Special Education)
Administrators/Non-instructional Staff
Other
What additional data do you anticipate requesting from CodeRVA?
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Required Attachments
Attach your research protocol here
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Attach the additional required documents here
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Certification of Application to Conduct Research
Read the following statement, then sign the document: I certify that my answers are true and complete to the best of my knowledge.
Signature
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Date
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Month
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Day
Year
Date
Submit
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