IRB Application

Except for grant-funded compensation and expenses, do you, or does any member of your immediate family, intend or expect to profit financially in any manner from the results of this research (including but not limited to any patent or licensing fees)?

No
Yes

Do you, or does any member of your immediate family, currently have or expect to have an ownership or other financial interest in, or management position with any entity whose procedure, technique, product, or software is used or tested in this study?

No
Yes

RESEARCH PROTOCOL:

Intended Use of Findings: (This might be for an class research paper, public presentation on campus, presentation at an academic meeting, possible publication, etc.)

RISKS TO PARTICPANTS: (Indicate what you consider to be possible risks, or inconveniences, to participants and what precautions are to be taken to minimize or eliminate these risks. Describe any procedures to be taken to monitor for adverse reactions or consequences of participation)

DECEPTION:

If “yes,” describe debriefing procedures to be used and attach copy of debriefing statement to be given at conclusion of the study.

CONFIDENTIALITY/PRIVACY: Describe how confidentiality will be preserved. If the study involves retaining confidential materials containing participants identity, explain where the materials will be stored, who will have access, how long they will be maintained, and what will be done with them after the study is completed.

COMPENSATION/PAYMENT:

INVESTIGATOR’S PLEDGE: I affirm the accuracy of this application, and I accept the responsibility for the conduct of this research, the supervision of human subjects, and maintenance of informed consent documentation as required by the Institutional Review Board. I will report promptly any unexpected or otherwise significant adverse effects encountered in the course of this study. This is to certify that the project identified above will be carried out as approved by the IRB, and will neither be modified nor carried out beyond the period approved without express review and approval by the IRB.

REQUIRED ATTACHMENTS

Individual Investigator Agreement(s) (signed)
Copy of informed consent document

ADDITIONAL ATTACHMENTS (as available or applicable)

Any recruitment notices or advertisements
Any survey instrument, psychological tests (other than standard, commercially available instruments), interview forms, or oral-
Any interview scripts to be used in the research
Formal research protocol, if available
Grant application, if applicable
Certificate of completion of education or training in the protection of human research subjects, if PI has one.

GRADUATE STUDENT REQUIREMENTS

NIH Training Certificate
Signed Approval of Graduate Research Proposal Form

Applications involving surveys of Hilbert College students, faculty, staff, or alumni will be forwarded to the Office of Institutional Advancement for inclusion on the college’s survey calendar.

Hilbert College IRB Application

INVESTIGATOR INFORMATION:

PROJECT INFORMATION:

CONFLICTS OF INTEREST:

RESEARCH PROTOCOL:

DECEPTION: