IRB – Submission of a Research Study Form

If you are human, leave this field blank.

Demographics

Type of Review being Review Requested *

Note: Irrespective of the type of review requested, please fill out the full application.

Full Review

Expedited

Exempt

Demographics

Title of Proposed Research Study *

Synopsis *

Principal Investigator/Researcher *

Highest Degree Completed *

Email *

Phone *

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

Highest Degree Completed

Phone

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

Highest Degree Completed

Phone

Study Site (select all that apply) *

Main Campus

TEC

Pioneer

High School (list all high schools that apply)

Will subjects receive remuneration for participation? *

Yes

Will any type of deception or partial disclosure be used *

If YES, please submit a full review application.

Yes

Explain why this research proposal should be Exempt. Please refer to the 45 CFR 46 Guidelines.

Have all research personnel completed the Protection of Human Subjects Research training? *

Yes

If NO, please do not submit this application until done. This training is free at OHRP Human Research Protection Training. If YES, please attach the certificate. We will accept any certificate that is five or fewer years old.

The Proposed Study *

The Proposed Study

Title of the Study *

Purpose of the Study: Hypothesis(s) *

Purpose of the Study: Objective(s) *

Purpose of the Study: Rationale(s) *

The Proposed Study (Cont.)

Duration of Study

Note: The duration must be under 12 months. If the duration is more than 12 months, an Application for Extension should be made at the beginning of the tenth month.

Purposed Start Time *

Proposed Start Time *

Will This Study Culminate In *

Thesis

Dissertation

Other (specify)

Will this study be published? *

Yes

Do Not Know

Give the relevant background: Abstract or Summary of previous/related studies and criteria for inclusion in the study. *

Give the relevant background: Abstract or Summary of previous/related studies and and criteria for exclusion in the study. *

Explain the Research Design

Attach Timeline for the Study

File types allowed: .doc, .docx, .txt, .pdf

Attach a Consent Form

See HHS/OHRP Consent Form Checklist - https://www.hhs.gov/ohrp/regulations-and-policy/guidance/checklists/index.html. File types allowed: .doc, .docx, .txt, .pdf

Research Design, Including Tests and Measures. Describe all procedures and who will conduct each. *

Attach All Study Instruments

File types allowed: .doc, .docx, .txt, .pdf

Are these instruments yours? *

If Yes, were they checked for validity and reliability?

If No, did you gain permission to use them?

If you did gain permission, please attach the permission.

File types allowed: .doc, .docx, .txt, .pdf.

What is the estimated time commitment from each participant (in minutes)? *

Will photography, audio and/or video recording occur in the collection of data? *

Photography

Audio

Video

If yes to any of the three, please state how anonymity will be addressed.

Describe as clearly as possible any risks or discomforts associated with this study, whether physical, psychological, economical, or social (e.g., invasion of privacy, breach of confidentiality, stress) commenting on the probability of potential to harm. *

Describe the recruitment procedures; include copies of all promotional and recruitment materials. Explain clearly who will do this and how. *

Note

If an IRB Approval from another institution is required before this study can commence, make that approval letter a part of this study packet. Your study proposal packed is incomplete without it. Also, getting an approval from one institution does NOT automatically signal approval from the KCKCC-IRB.

Will there be any link between identifiers and specific participants? *

If Yes, how long will this be kept? *

If yes, will this information be shared with anyone outside of your research team group? *

If Yes, why and whom?

Will this study involve any form of deception? *

If Yes, check the relevant boxes below:

Academic records

Any form of invasion of privacy

Social risk (e.g., ostracization)

Any form of psychological stress

Economic risk (e.g., potential loss of employment)

Legal risk (e.g., potential lawsuits)

Others

If Yes, please explain HOW and WHY?

Describe how the risks discussed above will be minimized.

How will this study benefit the participant?

As the Principal Investigator, I have the definitive accountability for all aspects of this study. I herewith assure that:

All the information provided in this application is truthful to the best of my knowledge.
I will not change any of the protocols without first getting further approval from the KCKCC-IRB.
Any complaints from participants will be attended to appropriately and immediately.
Any participant may select to withdraw at any stage of the study.
I will submit a full copy of the report.

Signature of Principal Investigator *

Date *