IRB Submission for Extension (or to Make Changes)

I. Demographics

Title of Proposed Research Study: *

Synopsis: *

Principal Investigator/Researcher:

Name *

Highest Degree Completed: *

Email *

Phone *

Co-Principal Investigator/Co-Researcher (if applicable):

Name

Highest Degree Completed:

Phone

Co-Principal Investigator/Co-Researcher (if applicable):

Name

Highest Degree Completed:

Phone

Co-Principal Investigator/Co-Researcher (if applicable):

Name

Highest Degree Completed:

Phone

Study Site (select all that apply): *

Main Campus

TEC

Pioneer

High School (list all High Schools that apply)

Use this space to list the High Schools:

Date of original KCKCC - IRB approval: *

Was this extension or change(s) anticipated as a part of the original research design? *

Yes

Why do you need this extension (or make this change/s)? *

What would happen if you do not get this extension? *

Would this extension necessitate a new Consent Form? *

(see HHS/OHRP Consent Form Checklist)

Yes

Assurance Agreement

As the Principal Investigator, I have the definitive accountability for all aspects of this study. I herewith assure that: a) All the information provided in this extension application is truthful to the best of my knowledge. b) I will not change any of the protocols without first getting further approval from the KCKCC-IRB. c) Any complaints from participants will be attended to appropriately and immediately. d) Any participant may select to withdraw at any stage of the study. e) I will submit a full copy of the final report.

Signature *

Reset Signature

Signature is required.