Research Proposal Form
Special Education Studies
REVIEW FORM
Your Name(s):
Project is for which
course/requirement?
Instructor or research advisor?
Phone/E-Mail:
Please, answer each of the following questions. Additional information may be required by the
Review Committee if the responses are not sufficiently clear. (Attach additional page(s) if
necessary.)
A. Research Study
1. What is the start date of your study, and what is the projected end date?
2. What is the socially significant problem of your study?
3. State clearly the major purpose of your study.
4. Who will be the subject(s)? (Name and briefly describe).
5. What will be the setting? (Give name of school or agency and teacher or other relevant
person(s) involved in the study).
6. Operationally define the dependent variable(s) or behavior(s) and how it will be
measured.
7. Describe in some detail the independent variable(s) or intervention(s).
8. What experimental design will be used (specify the particular type of single-case or group
design that will be employed)?
B. Consideration of Human Subjects
1. Are there any foreseen risks to the subject(s) of your intervention? Yes/No
If "yes", specify.
2. What information concerning the research will be shared with each subject?
3. What information concerning the research will be shared with the parent/guardian,
teacher/supervisor, and/or other relevant person(s)?
4 Will you keep anonymous/confidential the child's/subject's name, teacher's/supervisor's name,
school's name and/or other identifying information? Yes/No
What information regarding the subject will be made public?
5. How is informed consent obtained and filed for each subject?
Is this procedure a typical procedure used in the classroom? Yes/No
If so, please have teacher initial here:
Is the targeted behavior one related to an IEP objective for the child? Yes/No
If so, please have teacher initial here:
Please, have the teacher, principal, parent, and/or other relevant person(s) responsible for the
subject(s) of this study sign below or have them sign a separate informed consent form and attach to
this completed form.
I have read the above proposal and give my permission for
(Name(s) of researcher(s))
to collect and use data regarding
in the research write-up and
(Student's/child's/client's name)
presentation. I understand that no names or other information that would identify the subjects in this
copy will be used in the write-up or presentation. Only the relevant people should sign below.
(Researcher Signature)
(Researcher Signature)
(Teacher Signature)
(Parent/Guardian Signature)
(Student/Child/Client)
Revised 10/16/03