DEC Research Request

Please enter responses for all of the following fields.

How many researchers are participating in your project? *

1 2 3 4 5 or more

Name of Researcher *

First Name Last Name

Institutional Affiliation(s) for Researcher *

Email Address for Researcher *

Mailing Address for Researcher *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Name of Researcher (2)

First Name Last Name

Institutional Affiliation(s) for Researcher (2)

Email Address for Researcher (2)

Mailing Address for Researcher (2)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Name of Researcher (3)

First Name Last Name

Institutional Affiliation(s) for Researcher (3)

Email Address for Researcher (3)

Mailing Address for Researcher (3)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Name of Researcher (4)

First Name Last Name

Institutional Affiliation(s) for Researcher (4)

Email Address for Researcher (4)

Mailing Address for Researcher (4)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

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: *

Month Day Year

Identify Expected Date for End of Research: *

Month Day Year

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, access to members 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 Research Request