Form #7
Kwantlen Polytechnic University
RESEARCH ETHICS BOARD
Student Research Proposal for Course-based, Minimal Risk
Research
This form is to be submitted to your instructor prior to the start of data collection.
Student Name(s): Click here to enter text.
Instructor: Click here to enter text.
Date: Click here to enter a date.
Title of Research Project: Click here to enter text.
Research Question(s) or Hypothesis(es): Click here to enter text.
Brief Summary of Procedures: Click here to enter text.
Description and Number of Participants / Method of Recruitment: Click here
to enter text.
_________________________
Student Signature
March, 2009
_________________________
Date
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Checklist of Requirements
Required tutorial on the Tri-Council Policy Statement for ethics in research
See http://www.pre.ethics.gc.ca/eng/resources-ressources/news-nouvelles/nrcp/2011-06-15/
I have completed the TCPS tutorial and attached a copy of my
certificate.
Requirements for minimal risk research
See “Criteria for Minimal Risk”, below
I have completed the section on minimal risk and determined, to the
best of my ability, that this research does not present more than minimal
risk.
Informed consent
See “Fill-in-the-blanks Consent Form”, below
I have attached the informed consent form that will be given to
prospective participants.
March, 2009
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Criteria for Minimal Risk
Minimal Risk is defined in the TCPS as follows: “if potential subjects can reasonably
be expected to regard the probability and magnitude of possible harms implied by
participation in the research to be no greater than those encountered by the subject in
those aspects of his or her everyday life that relate to the research then the research
can be regarded as within the range of minimal risk.”
To further assess minimal risk, please complete the following checklist.
This research project involves:
Research on sensitive topics that could cause distress to research
subjects/participants
Action research
Deception (e.g. research in which some aspect of the procedure is
deliberately misrepresented or withheld from the subject for experimental
purposes)
Recruitment via telephone, except by random digit dialing
Database linkage where personal identifiers are being used to
probabilistically link one or more existing databases with new databases or
surveys
Use of oral consent or passive consent
Inclusion of research subjects/participants who are less than 19 years of age
(unless these are confirmed Kwantlen students)
Inclusion of research subjects/participants who are unable to be fully
informed, such as those with mental disabilities or dementia
Access to medical records
Recruitment of patients by physicians or medical staff
Surveys using online survey companies (e.g. Survey Monkey or
Zoomerang) that analyze, store or process the data outside of Canada
Any videotaping, photographing, or digital image recording, unless the
images show no identifiable people or places
Focus Groups in which personal, sensitive, or controversial issues are
discussed
Checking any of the above indicates research greater than minimal risk and requires
ethical review from Kwantlen’s Research Ethics Board (REB).
March, 2009
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RESEARCH ETHICS BOARD
Fill-In-The-Blanks Consent Form
Copy the following and produce your consent form including appropriate versions
of the statements at the beginning and fill in the information left blank. You must
begin with the statement about voluntary participation that assures participants
that participation is voluntary and that they may withdraw at any time.
Items in square brackets are comments on the format, not elements to be included.
Title of Research Project: Click here to enter text.
Principal Investigator: Click here to enter text.
Application # ___________________ [You will get this later but before you ask for
consent.]
Voluntary participation:
Your participation in this research project is completely voluntary. You have the right to
withdraw from the research study at any time. Even if you do not want to join the study
or if you withdraw from the study, you will still receive [For students say this.] the same
quality of instruction [or for employees use this] benefits and opportunities that other
employees receive. Your decision also will not jeopardize your [for students] grades or
studies [For employees say this.] employment or income at Kwantlen. You should ask
the principal investigator listed below any questions you may have about this research
study. You may ask him/her questions in the future if you do not understand something
that is being done. The investigators will share with you any new findings that may
develop while you are participating in this study.
This consent form explains the research study you are being asked to join. Please review
this form carefully and ask any questions about the study before you agree to join. You
may also ask questions at any time after joining the study. See below for persons to
contact.
[See the application guidelines for help in filling in the following information.]
Purpose of Research Project: Click here to enter text.
Procedures: Click here to enter text.
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Risks of harm/Discomforts/Inconvenience: Click here to enter text.
Benefits [including compensation if any]: Click here to enter text.
Alternatives to Participation for Similar Benefits: Click here to enter text.
Confidentiality: Click here to enter text.
Persons to Contact:
If you want to talk to anyone about this research study because you think you have not
been treated fairly or think you have been hurt by joining the study, or you have any other
questions about the study, you should call the principal investigator, Click here to enter
text. at Click here to enter text. or call the Kwantlen Office of Research and Scholarship
at 604-599-2373 [Research done in an international setting should use a local name and
telephone number. Where this is not useful to participants, some other appropriate
means of getting help and information must be given in detail.]
Once you have read this document, or the document has been read and explained to you,
and you have been given the chance to ask any questions, please sign or make your mark
below if you agree to take part in the study.
Print Name of Subject:___________________________________________________
___________________________________________
Signature or Mark of Subject or Legally Authorized
Representative
___________________
Date
___________________________________________
Signature of Person Obtaining Consent
___________________
Date
___________________________________________
Witness to Consent if Subject Unable to Read or Write
(Must be different than the person obtaining consent)
___________________
Date
Signed copies of this consent form must be 1) retained on file by the principal
investigator, 2) given to the subject and 3) placed on file in the Office of Research
and Scholarship at Kwantlen Polytechnic University.
March, 2009
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