• Application to Conduct Records-Based Research

    Research Ethics Committee

  • This form is for records review research proposals only. Please complete each section as it applies to your research. If additional space is needed to fully explain any of the requested information, please upload appendices in the space provided.

     

  • Please indicate if this is your initial or revised submission.*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • If you are gathering data from an organization's non-research data, is any member of the research team a member of that organization.
  • Is the full dataset to be gathered publicly available?*
  • Will any identifiable private information be recorded in the research database?*
  • Is the data being reviewed /collected for either of the following purposes?*
  • Does the proposed records-based research present any more than minimal risk to human subjects (or could it if the data were disclosed)? (Note: risk is not limited to physical risk and may also include risk to socioeconomic status, employability, emotional well-being, reputation, etc.)*
  • Does the proposed records-based research involve access to protected health information (PHI)?*
  • If yes, has the PHI been de-identified?
  • If the PHI has not been de-identified, has a Data Use Agreement with the HIPAA covered entity providing the data been obtained?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does the proposed records-based research involve access to personally identifiable educational records?*
  • Will informed consent be sought?*
  • Will authorization be sought? E.g., HIPAA authorization required for gathering PHI, which is separate from consent.*
  • Will / has broad consent be / been utilized?*
  • Have you separately submitted or will you submit to the REC an application for a waiver / alteration of informed consent?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does the investigator / study purpose meet any of the following conditions for waiver of consent? (select all that apply)
  • Estimated Starting Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Revised Documents

    This page is for uploading revised documents (after initial REC review) ONLY. Please use the following fields to upload your revised documents.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • FOR REC USE ONLY DO NOT FILL BELOW THIS LINE

  • Approval Recommended
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: