MODIFICATION/REVISION REQUEST FORM
University of Wisconsin Stout
Any proposed changes to previously approved human subjects research must be reviewed and approved by the IRB prior to
implementation. To request a modification or a revision this form must be filed at least 10 days prior to making any changes. Data
collection/analysis cannot begin until there has been IRB approval.
Directions:
1. Complete this form on-line and print. Handwritten forms will not be accepted. For your benefit, save your completed
form in case it needs to be revised and resubmitted.
2. Send or take the completed form, with required signatures and materials attached, to Research Services, 152 Voc. Rehab.
Building; IRB@uwstout.edu.
Project Title:
Dates of initial approval for this research project: Beginning Date:
Ending Date:
Investigator(s):
Name:
ID:
e-mail address:
Daytime Phone #
Program:
Graduate Student:
Signature: _______________________________________
Undergraduate:
Name:
ID:
e-mail address:
Daytime Phone #
Program:
Graduate Student:
Signature: _______________________________________
Undergraduate:
Name:
ID:
e-mail address:
Daytime Phone #
Program:
Graduate Student:
Signature: _______________________________________
Undergraduate:
For students:
Research Advisor's Name:
Department:
Signature: _______________________________________________________________ Date of Approval: __________
Research Advisor: Have you completed UW-Stout’s Human Subjects Training? Yes
No .
Are you requesting a revision/modification of a research project that has received IRB approval? Yes
No
If no, please use the Protection of Human Subjects Form found at http://www.uwstout.edu/rs/upload/humnsubjform-doc.docx
Describe any and all changes you wish to make to this research project, and address the risks and benefits of these changes. This
includes modifications to the study, recruitment methods, research personnel, or any revised material.
Projects that are not completed within one year of the IRB approval date must be submitted again. Annual review and approval by
the IRB is required. Projects that are determined to be exempt from IRB review hold exempt status for a period of 5 years, unless
there are significant changes to the project.
Updated 1/31/2014