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