Human Research Protection Program-Institutional Review Board American University of Beirut Form for Release of Students E-mail Addresses for Research Projects Date: Name of Principal Investigator: ____________________________________________ Title of Study: _________________________________________________________ IRB Protocol Number: ___________________________________________________ Approval date ___________________________________________________ Brief Description of Study Purpose: _________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Check applicable item: Request for a LIME Survey to conduct study Request to send invitation for a research study _________ _________ Only a subset of students from either undergraduate or graduate groups and their email addresses shared will be selected based on criteria specified below. Please specify the group(s) of interest: ___ Undergraduate students ___ Graduate students ___ Own database of students’ emails. Please specify: 1) Source of emails’ addresses in own database: 2) Total number of emails: ___________ ___________ ______________________________________________________________________ PLEASE NOTE THAT UNIVERSITY POLICY PRECLUDES SENDING A MASS EMAIL TO ALL MEMBERS OF ANY ONE GROUP Please specify the number or percentage of email addresses within the targeted group as justified and stated in the approved IRB protocol: Approximate number of E-mail Addresses Requested for Undergraduate: ____________ Approximate number of E-mail Addresses Requested for Graduate: ____________ Approximate number of E-mail Addresses desired from own database ____________ Version #1.1 Version Date: September 17, 2013 Human Research Protection Program-Institutional Review Board American University of Beirut Form for Release of Students E-mail Addresses for Research Projects Or Percentage of targeted student population to receive email for Undergraduate: ____________ Percentage of targeted student population to receive email for Graduate: ____________ Percentage of Email Addresses desired from own database: ____________ If request is DECLINED, the PI will need to resubmit a modified strategy and protocol to the IRB for reconsideration and approval. Please submit completed form with the IRB application or send to the IRB for processing. ________________________________ Principal Investigator’s Signature ___________________________ Date Please do not fill below this line ______________________________________________________________________ o I hereby approve the release of the requested email lists as indicated above OR o I hereby decline the request above for release of email addresses. _____________________________ Talal Nizameddin, Ph.D. Dean of Student Affairs ________________________________ IRB Acknowledgment of receipt Stamp Version #1.1 Version Date: September 17, 2013 ____________________________ Date