Revised 10/30/2014
Cooperative Research Approved by Non-Winthrop IRB
NAME OF PROJECT
WINTHROP UNIVERSITY RESEARCHER OF RECORD
RESEARCHER OF RECORD
DEPARTMENT
EMAIL ADDRESS
PHONE CONTACT
OFFICE:
CELL:
APPROVING INSTITUTION
NAME OF APPROVAL BOARD
NAME OF INSTITUTION
ADDRESS OF INSTITUTION
NAME
PRINCIPAL RESEARCHER
EMAIL ADDRESS
OFFICE PHONE
CELL PHONE
Certifications
By my signature below, I certify that the protocol as attached has been reviewed, approved or exempted by a qualified review
board at the home institution shown above.
_____________________________________________________________
_______________________
Signature of Researcher
Date
By my signature below, I certify that I have reviewed this research study and agree to counsel the student researcher in all aspects
of the research study.
__________________________________________________________
_______________________
If Student Researcher; Signature of Faculty Advisor
Date
Approval by Department Chair of Researcher of Record
(Dean, if Chair is the Researcher or if Chair is otherwise unable to review.)
I have reviewed this research study. I believe the research is sound, that the study design and methods are adequate to achieve
the study goals, and that there are appropriate resources (financial and otherwise) available to the researcher. I support the
study, and hereby submit it for further review by the IRB.
_____________________________________________________________
_______________________
Signature of Department Head or Dean
Date