APPLICATION FOR CONDUCTING RESEARCH WITH HUMAN SUBJECTS
CALIFORNIA STATE UNIVERSITY, FRESNO
Instructions: This form is to be completed by those conducting research with human subjects. Please
review the Policy and Procedures for Research with Human Subjects at California State University, Fresno,
(in the Student Corner on the Doctoral Program webpage) to help you define the category of exemption for
which you are applying.
Application Category (please check the appropriate category in which your research falls)
a. ☐Exempt (complete Section I and Section II)
b. ☐Minimal Risk (complete Section I and Section III)
c. ☐ At Risk (complete Section I and Section III.) Research in this category will also need to be
reviewed by the University Board on the Protection of Human Subjects
Please attach the following materials to your application and check the boxes to indicate they are
attached.
1. ☐Copy of Chapter 3
2. ☐Copy of Survey or Research Instrument
3. ☐Copy of Informed Consent
4. ☐Appropriate signature from Dissertation Chair
Note: Incomplete applications will not be processed. Incomplete forms will be returned for the required
information. No data collection involving human subjects may take place until the proposal has been
approved by all required reviewers.
Section I.
Complete all sections. If a section is not applicable, indicate with N/A
Student Information
Name:
Student ID:
Phone:
Title of Study:
Principal Investigator
Name:
Department:
Mail Stop:
Phone:
1.
DPELFS Form 5
APPLICATION FOR CONDUCTING RESEARCH WITH HUMAN SUBJECTS
Section II.
Exempt: If you believe that your research project is exempt from full review by the
Committee on the Protection of Human Subjects. Please complete this section.
Student’s Statement of Exemption
In my judgment, my proposed research involving human subjects is exempt from consideration.
The following section(s) of the CSUF “Policies and Procedures for Research with Human
Subjects” apply to my research and to my statement:
_____3.5.2A
_____3.5.2B
_____3.5.2C
_____3.5.2D
_____3.5.2E
_____3.5.2F
Statement of Basis for Exemption:
Student Signature
Date
Expires one year from above date.
Principal Investigator Signature
Date
Human Subjects Research Exemption Reviewer Response:
_____ 1) I hereby verify that your proposed research is exempt from further Human Subjects
review.
______2)
This research appears not to be in one of the exempt categories. Your proposal is
being forwarded for review by 3 department faculty.
DPELFS Director or Designee Signature
Date
2.
APPLICATION FOR CONDUCTING RESEARCH WITH HUMAN SUBJECTS
Section III.
Minimal Risk and At Risk Research: A departmental review by at least three faculty
who are not involved in the research under consideration is required for research that
does not meet exempt status. Each faculty reviewer should indicate whether they believe
the research is Minimal Risk or At Risk.
Name
Level of Risk
Principal
Investigator:
☐At Risk
☐Minimal Risk
Reviewer:
☐At Risk
☐Minimal Risk
Signature
__________________________________________
PI Signature
Approve:
Disapproved:
Comments:
Reviewer:
☐At Risk
☐Minimal Risk
Approve:
Disapproved:
Comments:
Reviewer:
☐At Risk
☐Minimal Risk
Approve:
Disapproved:
Comments:
Principal Investigator notified of HS approval on
by
3.
(date)
(name)