IRB Application for Determination of Exemption

Note: Interviews and surveys with children are NEVER exempt.

Date Date / MM / DD YYYY
1. Title of Study
List principal investigator (P.I.) and all sub-investigators. If you have additional investigators, use the Upload button to submit a document that details additional investigators.
2. Principal Investigator 2. Principal Investigator First Last
Dept./University
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Name Name First Last
Dept./University
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Name Name First Last
Dept/University
Name Name First Last
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3. Research Period:
NO Research activity may be conducted until formal IRB approval. This includes advertising, subject recruitment, data collection, etc.
Project Start Date Project Start Date / MM / DD YYYY
Project End Date Project End Date / MM / DD YYYY
4. Reason for conducting research:

4. Reason for conducting research: Professional Dissertation Thesis Class assignment Capstone Project Other: Specify Other: Specify
5. Sources of funding
6. This research involves (check all that apply):

6. This research involves (check all that apply): Collection or study of existing data, documents, records or specimens Normal educational practices conducted in established or commonly accepted educational settings Educational tests (cognitive, diagnostic, aptitude, achievement) Observation of public behavior Survey interviews: Indicate method below
Survey Method
Any possibility of identifying a subject (discuss in cover letter) The possibility that the subject's responses or conduct (if they became public) may place the subject at risk of criminal or civil liability or be damaging to the subject's financial standing or employability Sensitive aspects of personal behavior (for example:illegal conduct, drug use, sexual behavior or use of alcohol) Investigator's participation in activities being observed Only surveys or interviews of elected or appointed public officials or candidates for public office Audiotaping Children under age 18 (see Chapter 2 of the Waynesburg University guidelines) Research is conducted by or subject to approval by a governmental agency Taste and food evaluation or consumer acceptance Web-based or electronic and/or other
Explain
NOTE: INTERVIEWS AND SURVEYS WITH CHILDREN ARE NEVER EXEMPT
7. Please provide an abstract (a brief summary of the purpose and procedures), written in language that can be understood by the non-specialist.
8. Goal of research
9. Provide a detailed summary of your proposed project, including a) consenting process, b) a detailed explanation of confidentiality or anonymity, and c) all other procedural elements. Be sure to include a detailed explanation of data collection procedures.

9. Provide a detailed summary of your proposed project, including a) consenting process, b) a detailed explanation of confidentiality or anonymity, and c) all other procedural elements. Be sure to include a detailed explanation of data collection procedures. Anonymous Confidential
10. Describe and explain any risks, discomforts, and benefits to the subjects, the scientific community, and/or the local community. If no known risks, state same.
12. Estimate the number of subjects your plan to enroll
Smallest number of subjects from whom you plan to collect data at one time
13. Explain how records will be kept. Describe how paper, electronic, and/or media files will be stored and secured during the study and how they will be disposed at the end of the study.
14. Provide comments on applicable HIPAA elements if patient records/data will be assessed.
15. Do you have any evaluation responsibilities over any of your subjects?

15. Do you have any evaluation responsibilities over any of your subjects? No Yes
If yes, please describe
16. Attached are:

16. Attached are: script that introduces/explains your project the questionnaire/survey to be used (If you are using a questionnaire or survey that was developed by someone else, please provide evidence stating you have their permission to use the instrument). telephone text (including remarks as in a cover letter--see below) permission from external institution (on their letterhead), if applicable cover letter
A cover letter addressed to respondents must accompany any survey or questionnaire. The cover letter must be on your departmental letterhead and must include the following:
a. a statement that the project is research being conducted in partial fulfillment of the requirements of a course, master's thesis, dissertation, etc.,
b. purpose of study
c. a statement that subjects' responses will be kept anonymous or confidential (explain extent of confidentiality if subjects names are requested),
d. if audio taping: a statement that subject is being audio taped (explain how tapes will be stored or disposed of during and after the study),
e. a statement that subjects are not required to answer every question,
f. a statement that class standing or grades (or status of an athletic team, if applicable) will be affected by refusal to participate or by withdrawal from the study,
g. a statement that participation is voluntary
Upload any attachments here

Attach Files
Faculty Advisor Faculty Advisor First Last
Department Chair/Program Director Department Chair/Program Director First Last
I certify that all investigators have completed PHRP or CITI training. Please provide a copy of certificate of completion for each.
17. Signature
My signature below indicates: 1) that I am submitting this protocol as the principal investigator and 2) that I have read the Waynesburg University IRB Policy and have had the opportunity to have any questions answered.
Upload a copy of each certificate

Attach Files
Principal Investigator's name Principal Investigator's name First Last
Date Date / MM / DD YYYY
Principal Investigator's signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

IRB Application for Determination of Exemption

IRB Application for Determination of Exemption

NOTE: INTERVIEWS AND SURVEYS WITH CHILDREN ARE NEVER EXEMPT