Recruitment of Students as Research Participants in Medical Education Studies Request Form

Office of Student Research Bressler, Suite M-019 655 West Baltimore Street Baltimore, MD 21201 410 706 3026 StudentResearch@som.umaryland.edu http://medschool.umaryland.edu/osr

Recruitment of Student as Research Participants in Medical Education Studies

All requests for advertising support, to help recruit UMSOM students to serve as participants in medical education studies, will be considered on a case-by-case basis. For consideration, a UMSOM faculty member must be a PI or Co-I on the project. Additionally, the project must have UMB IRB approval that includes recruiting students as well as provisions regarding how to protect students as potential vulnerable populations. Investigators should not utilize Dean’s office list servs without prior approval. Furthermore, it is not acceptable for investigators to work directly with student groups without prior Dean’s office approval. In order for your medical education research to be reviewed and considered for distribution, complete this form. The appropriate academic Dean’s office committee(s) will review each request individually to ensure adequate protection of the student participants.

This form should be completed by the project PI or the UM SOM PI.

Please submit a separate entry for each project or proposal.

Basic Request Information

Project PI (Must be Faculty, Clinician, or Clinician-Scientist)

1. First Name or Known Name (Project PI) *

1. Last Name (Project PI) *

1a) E-mail (Project PI) *

1b) Is the PI a UM SOM faculty? *

Yes No

UMSOM PI (Must be UMSOM faculty member)

2. First Name or Known Name (UMSOM PI) *

2. Last Name (UM SOM PI) *

2a) E-mail (UMSOM PI) *

Project

3. Site *

UMSOM

4. Project Title *

5. Brief Project Description *

6. Special contact instructions or contact person, if applicable.

IRB

Reminder: Faculty are responsible for any regulatory requirements including IRB.

7. Has IRB approval or determination been obtained? *

IRB protocol submitted for review, approval pending IRB approved IRB determined as Exempt IRB determined as Non-Human Subjects Research, not need IRB review

7a). IRB protocol number *

7b). IRB original approval or determination date *

7c). IRB latest approval date if modified or renewed (enter N/A if not applicable) *

7d). IRB current expiration date *

7e). Upload a copy of the latest IRB approval/determination letter *

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7f). IRB other circumstance - Explanation *

8. Does the IRB protocol include acknowledgement that students were being targeted for recruitment? *

I confirm that acknowledgement was included in the IRB protocol. Acknowledgement was not included in the IRB protocol.

9. List the types of students you plan to recruit/enroll. If IRB approval obtained or pending, please list the types of students selected in the IRB proposal. *

10. What provisions were made to protect students from any undue influence? *

11. List all methods of recruitment you hope/plan to use to enlist student participation (e.g. advertisement, flyers, emails, websites, in person, etc.). If IRB approval obtained/pending, please list the methods of recruitment indicated in the IRB proposal. *

12. Are students being compensated for participation? *

Yes No

12a). Students are being compensated - provide details of compensation. *

Additional Items If Applicable

13. How many students are needed?

14. Expected time frame of commitment (length of time and/or specific date range)

14a). Expected date students will begin as participants.

15. Qualifications or restrictions.

16. Relevant supporting documents, if applicable (multiple files can be uploaded)

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Additional Comments

Signature

Signature of PI or UM SOM PI submitting this request *

Clear

Full Name of the person signed *