Institutional Review Board (IRB) Application
Institutional Research Office
Primary Investigator Information
Date
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Month
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Day
Year
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Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Status
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LC Faculty
LC Administrator
LC Staff
LC Student
Other
Has Collaborative Institutional Training Initiative (CITI) human subjects training been completed in the past 3 years?
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Yes
No
Does this project have a co-investigator?
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Yes
No
Co-Investigator Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Status
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LC Faculty
LC Administrator
LC Staff
LC Student
Other
Has Collaborative Institutional Training Initiative (CITI) human subjects training been completed in the past 3 years?
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Yes
No
Project Information
Project Title
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Anticipated Start Date
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Month
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Day
Year
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Anticipated End Date
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Month
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Day
Year
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Indicate the type of review requested.
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Exempt
Expedited
Full
Indicate which of the following populations will be studied. Select all that apply.
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LC Students
LC Employees
Other
List all locations where study activities will take place.
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Will other institutions other than LC participate in the study?
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Yes
No
List the additional institutions.
Has IRB approval been received from the institution(s) listed above ?
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Yes (please submit a copy of the approval letter)
No
Please provide the research question(s) for the study.
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Please summarize the purpose of the study.
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Please describe the process for collecting data for this research. It is recommended that the process be describe in steps e.g. Step 1, Step 2,...
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Select all that apply for collecting data/information in the study. Please submit a copy of any surveys or standardized tests used. If using interviews or focus groups please submit the questions.
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Survey
One-on-one interviews
Focus groups
Standardized test
Other
Please upload copies of surveys and interview scripts used in your research.
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Browse Files
Drag and drop files here
Choose a file
Cancel
of
Select all that apply for collecting data/information.
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In-person
Telephone
E-mail
Zoom
Mail
Other
Please list any demographic variables that you plan to collect e.g. age, gender, ethnicity... and explain how they are connected to the research question(s).
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Participants
Approximately how many participants will be recruited for the study?
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Less than 10
11-20
12-30
31-50
51-100
Over 100
Please select any vulnerable populations that will be recruited for the study
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Children under 18 years of age
Pregnant women
Prisoners
Individuals with physical disabilities
Individuals with mental or cognitive impairments
Educationally or economically disadvantaged
No vulnerable populations will be recruited
If vulnerable populations will be participating in the study, please discuss the special protections being implemented to minimize the risk of coercion or undue influence .
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What are the primary inclusion criteria?
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What are the primary exclusion criteria?
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Will compensation be offered?
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Yes
No
Please describe the type and value of the compensation.
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Please describe the recruitment process, including any advertisements (flyers, emails, phone scripts, etc.) to be used for this study.
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Risks/Benefits
Please describe any potential risks and how these risks will be minimized.
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Please describe any potential benefits.
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Confidentiality
Please describe the steps to ensure the confidentiality of the participants and data.
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Please describe where and how the data will be stored.
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How long will the data be retained?
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Less than 1 year
1 to 2 years
Over 2 years
Please describe how the data will be disposed.
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Informed Consent
What type of informed consent will be obtained?
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Written consent with signature
Consent without a signature (online survey)
Verbal consent (interviews)
Other
Describe the informed consent process. How and by whom will initial contact with potential subjects take place?
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Please copy the informed consent to be used.
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Assurance
I certify that the information provided in this application is complete and correct to the best of ability and knowledge
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Yes
I understand that as Principal Investigator, I have ultimate responsibility for the conduct of the study, the ethical performance of the project, the protection of the rights and welfare of human subjects, and strict adherence to any stipulations imposed by the IRB. I accept responsibility to ensure that all study personnel are adequately trained for their role and have read this application.
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Yes
Date
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Month
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Day
Year
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Submit
IRB Office Only
IRB application assessment for Exempt applications
Accept
Resubmit with modifications
Recommend submitting as a Level 2 or 3
Deny
IRB Number
IRB application assessment for Expedited applications
Accept
Resubmit with modifications
Recommend submitting as a Level 3
Deny
IRB Number
IRB application assessment for Full Committee applications
Accept
Resubmit with modifications
Deny
IRB Number
IRB Signature
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