UNIVERSITY OF PHOENIX INSTITUTIONAL
REVIEW BOARD APPLICATION TO CONDUCT
RESEARCH USING HUMAN SUBJECTS
The University of Phoenix Institutional Review Board (IRB) must review all requests to
conduct research involving human subjects. Present the request in TYPEWRITTEN form
and in non-technical terms understandable by the IRB. If this is a pilot study, the IRB
application must be approved prior to conducting the study. If the study is based on a
developed instrument, the IRB application may be turned in with the proposal.
Please note that it is the researcher’s responsibility to give complete information about
the benefits and risks entailed by the proposal. To assist the IRB in its review, please
submit a copy of your complete proposal and the informed consent forms, along with all
materials and background information. If you are faculty and/or staff, a copy of your
curriculum vitae or biographical sketch is also required.
AFFILIATION
(STUDENT,
FACULTY, OR
STAFF)
TYPE OF RESEARCH
(RESEARCH STUDY,
*FUNDED RESEARCH,
OR OTHER)
1.
Student
Research Study
2.
Faculty
Research Study
Faculty
3.
* If research is funded, please complete the following:
Research Study
NAME OF RESEARCHER(S)
AGENCY SUBMITTED TO
LOCATION /
DEPARTMENT
SUBMISSION DATE
/
Project title:
1. General purpose of the research:
/
LOCATION OF PROJECT
2. Project description: The IRB must have complete and detailed information about
what will happen with, or to, subjects in order to evaluate or estimate the potential
risks.
Explain whether subjects will encounter the possibility of stress or psychological, social, physical, or legal risks that are greater than
those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests. Assurance
from the investigator, no matter how strong, will not substitute for a detailed description of the transactions between investigator and
subject(s). If a questionnaire is used, attach a copy. Describe when visual or auditory stimuli, chemical substances, or other measures
might create a risk. In all cases, the IRB will require documentation.
Summarize the research methods & data collection technique
3. Will the subjects fall under the federal guidelines for vulnerable subjects listed
below:
The guidelines are defined at www.citiprogram.org
a. Age less than 18 years?
b. In prison?
c. Pregnant women?
d. Cognitively impaired?
Yes (
Yes (
Yes (
Yes (
)
)
)
)
Additionally,
e. Will the subjects be deceived or misled in any way?
f. Will subjects be students of University of Phoenix?
g. Will subjects be faculty or staff of the University of
Phoenix?
h. Will information be requested that might be considered
personal or sensitive?
No (
No (
No (
No (
)
)
)
)
Yes (
Yes (
Yes (
)
)
)
No (
No (
No (
)
)
)
Yes (
)
No (
)
4. Selection: How will subjects be selected, enlisted, or recruited?
Who will be excluded from this study and why?
5. Informed consent: How will subjects be informed of procedures, intent of the study,
and potential risks to them?
6. What are the potential benefits to a subject?
7. Privacy: How will subjects’ privacy be maintained and confidentiality guaranteed?
8. Proposed research start date:
/
End date:
/
/
/
9. Attachments: Please check all that apply.
Proposal
(
)
Informed consent forms
(
)
Data collection tool
(
)
(
)
Communication with subjects
(introductory letters)
(
)
(
)
Assent form (as child subject will
view it)
Curriculum vitae or biographical
sketch
Verbal script
(
)
Other documentation
(
)
In making this application, I certify that I have read and understand the Federal Policy for the
Protection of Human Subjects (45 CFR 690) and that I will comply with the University policies
governing the same.
I will submit proof of training in the protection of human subjects, found at
www.citiprogram.org
I also agree to submit a progress report as requested.
Principal investigator:
NAME:
SIGNATURE:
E-MAIL ADDRESS:
TELEPHONE #:
(
)
DATE:
-
MAILING ADDRESS:
Significant changes in protocol must be submitted to the IRB for written approval
prior to such changes being put into practice. Informed consent/assent records of the
subjects will be kept by the researcher for three (3) years after completion of the
research.
Faculty/advisor: (Complete this section if researcher is your student). I agree to
provide the proper oversight of this project to ensure that the rights and welfare of all
human subjects involved are properly protected.
NAME:
SIGNATURE:
DATE:
/
LOCATION:
DEPARTMENT:
/
TELEPHONE #:
(
In your opinion, is the research:
E-MAIL
ADDRESS:
)
-
Exempt (
)
Non exempt (
)
Why:
This application has been reviewed by the University of Phoenix IRB:
Exempt
( )
Expedited
Full review board ( )
Approved
( )
Deferred
( )
Disapproved
Approved with changes. See required changes below*
Third party verification sought
Project report date
# / /
*Changes or modifications/conditions for approval, or reasons for disapproval:
(
(
(
(
(
This application is good for one year from the start of the study.
REVIEWER’S NAME:
REVIEWER’S SIGNATURE:
DATE:
/
/
/
/
)
)
)
)
)