DEC Research Request

Please enter responses for all of the following fields.

How many researchers are participating in your project?*

Name of Researcher*

First NameLast Name

Institutional Affiliation(s) for Researcher *

Email Address for Researcher*

Mailing Address for Researcher*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of Researcher (2)

First NameLast Name

Institutional Affiliation(s) for Researcher (2)

Email Address for Researcher (2)

Mailing Address for Researcher (2)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of Researcher (3)

First NameLast Name

Institutional Affiliation(s) for Researcher (3)

Email Address for Researcher (3)

Mailing Address for Researcher (3)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of Researcher (4)

First NameLast Name

Institutional Affiliation(s) for Researcher (4)

Email Address for Researcher (4)

Mailing Address for Researcher (4)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If there are 5 researchers or more, please enter the remaining researchers' information below in the following format:

Name, Institutional Affiliation(s), Email Address, Mailing Address.

Use a full return after each entry. (See example below.)

Remaining Researchers

Identify Expected Date for Beginning of Research: *

MonthDayYear

Identify Expected Date for End of Research: *

MonthDayYear

Attach a copy of the IRB/HSC protocols/forms (including consent forms). *

Please condense these forms into a single document.

Attach a copy of the approval IRB/HSC letter.*

Note, while IRB/HSC approval is not a requirement for submission of a research request, it is a requirement of approval by DEC, so please be aware that the research committee cannot make a final recommendation until they have received a copy of the IRB/HSC approval letter.

Provide a concise, plain language summary of the purpose and anticipated outcomes of the research (100 words or less). *

0/100

Describe the study participants (including characteristics/roles and numbers).*

Describe the benefits, or the lack of benefit, for participation.*

Describe the risks of participation. *

List the research activities and procedures that would involve study participants.*

Describe the expected duration of participation.*

Describe what the researchers are requesting of DEC (e.g., time commitment, information sent to DEC member list). *

Describe how the resources that DEC is providing will be used in the research study.*

Describe what will be the benefit for DEC from this research study.*

Describe how DEC will be mentioned in any products or published materials that result from this research (e.g., as a contributor). *

Identify when DEC will get a copy of the final report and how can it be disseminated. *

Describe how the proposed project aligns with DEC stated ends policies.*

Describe how the proposed project aligns with DEC Recommended Practices.*

Have you completed your submission? *

Yes, my submission is complete.

Division for Early Childhood Email

example@example.com

Division for Early Childhood Research Request