Proposal for research study involving human subjects (2016)

Application for Research Involving Human Subjects
Date of Submission

MonthDayYearHourMinutes
Title of Project*
Student Researcher

First NameLast Name
E-mail
Principal Investigator (this must be the faculty research advisor if the project is being conducted by a student researcher)*

First NameLast Name
E-mail
Other Researchers
Proposed Start Date

MonthDayYear
Proposed End Date

MonthDayYear

Section 4: Privacy and Confidentiality
Will the data be collected with identifiers that will allow the researchers to determine the identity of the subject?*

YesNo
Will you make an audio recording of the subjects?

YesNo
Will you make a video recording of the subjects?

YesNo
Describe the methods you will use to safeguard the privacy of our participants.
Who has access to the identity of the subjects?*

Only members of the research teamThe identity of the subjects will be made publicData will not be collected with identifiers
Explain why the research team needs access to subjects' identity and how you will conceal the identity of the subject from people who are not part of the research team.
Explain why it is necessary to reveal the identity of the subject and indicate how this information will be used. The subject must be informed in writing how their identity will be used.
Describe how you will ensure the confidentiality of the data you collect. Include information regarding the storage of data, plans for publication or presentation of data, and disposition and destruction of data. *

Section 5: Informed Consent
Will you require your subjects to sign a statement indicating their informed consent to participate in the study? If the subject is under the age 18 or is otherwise legally incapable of providing consent, written consent must be obtained from the parent or guardian and verbal consent from the subject.*

YesNo
A copy of the form must be attached to this application. Sample forms are available on the Defiance College webpage: If you will make an audio or video recording of the subject, you must use the sample form that specifically requests permission to make the recording.*

Upload a File

Cancelof
Explain why you will not obtain written consent.
If your participants are under the age of 18 or otherwise legally incapable of providing consent will you require your participants to sign a statement indicating their assent ?*

YesNoNot applicable - participants are over the age of 18 and legally capable of providing consent
A copy of the assent form must be attached to this application. Sample forms are on the Defiance College webpage.

Upload a File

Cancelof
Explain why you will not obtain written assent.

Section 6: Signatures
Please print and sign the form below. The signed form must be submitted before your proposal may be reviewed by the IRB. Completed forms may be scanned and sent to irb@defiance.edu.

My signature on this form indicates that the above information is accurate. I understand that it is my responsibility to protect the rights and the welfare of my subjects. I will protect the confidentiality of the information provided by my subjects unless I have obtained their written permission to disclose this information to others.

Faculty advisor: As a faculty advisor I understand that it is my responsibility to insure that I and all students working on this project have received the training needed to conduct the study and to safeguard the wellbeing of the subjects with whom they will interact.

Signature of Principle Investigator _________________________________________________________________________

Date__________________________________________________________________________________________________

Signature of Faculty Advisor_______________________________________________________________________________

Date__________________________________________________________________________________________________

Please print this page, sign it, and email a scanned copy to irb@defiance.edu. Please keep a copy for your records.
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