STATE UNIVERSITY OF NEW YORK AT POTSDAM
INSTITUTIONAL REVIEW BOARD
Application Checklist for Exempted Review of Research
Project Title:
Project #
Indicate what type of research you are submitting:
Faculty/Staff research – You are collecting data from or about humans.
Use – Appendix B
Classroom project – Your students are collecting data from or about humans. Use – Appendix F
Training was completed for all researchers: All Co-Investigators, Student Researchers or Staff Members
must complete the CITI course for Human Subjects and indicate the date of completion.
Appendices:
Yes -----Yes
N/A
Appendix A – Level of Review Request – Required for all applications
Appendix B – Co-PI or Student Researcher Information Sheet – Used for Faculty/Staff
Research a separate App B must be completed for each additional researcher.
Appendix C – Source(s) of Financial Support
Appendix D – Conflict of Interest – Required only for applicants who have declared a
conflict of interest
Appendix E – Cooperating Organization Information Sheet
Appendix F – Classroom Project Information Sheet Students must complete this
appendix for Classroom Project Research – do not complete App B
Appendix G – Request for Permission to Solicit Research Participation on Campus
Electronically
Yes
Yes
N/A
N/A
Yes
Yes
N/A
N/A
Yes
N/A
Yes
N/A
Copies of research instruments are attached. (Surveys, interview questions, focus group
questions, screen shots of web based research, etc…)
Yes
N/A
Copies of recruitment materials are attached. (Advertisements, flyers, emails, letters,
phone scripts, web pages, etc…)
Yes
N/A
Letters of permission and/or IRB review from other organizations involved in the
project are attached. (Include appendix E)
Yes ----Yes ----Yes -----
The application has been signed by all researchers.
All questions have been answered or marked N/A.
All of the appropriate appendices have been attached.
Application Submission:
One complete paper copy of the application with original signatures was sent to the IRB Chair.
One complete electronic copy of the application was emailed to the IRB Chair.
Johanne Sullivan, Chair
Raymond Hall 204
Phone 267-2688
SUNYPotsdamIRB@potsdam.edu
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STATE UNIVERSITY OF NEW YORK AT POTSDAM
INSTITUTIONAL REVIEW BOARD
**NOTE - The IRB may need to request additional information in order to reach a decision regarding the
project’s eligibility for exemption.
SUNY Potsdam Application for Permission to Involve Human Subjects in Research Exempt Review
Project #
Exempt Review
Project Title:
Regular Application
Principal Investigator:
Classroom Project Application
Campus Mailing Address:
Phone Number:
Fax:
Email:
Department:
Supervisor:
Occupational Position:
Faculty
Staff
Non-employee
CITI Course/Refresher Course Completed
CITI course link
*Note – Students cannot be principal investigators and
must be supervised by a faculty or staff member
Date of completion:
https://www.citiprogram.org/default.asp
(refresher course is required every 3 years)
I have read Appendix D Conflict of Interest guidelines and the SUNY Potsdam Conflict of Interest Policy
and declare that I do not have a potential conflict of interest associated with this project.
I have read Article 24-A as amended to the New York State Public Health Law (available on the SUNY
Potsdam IRB website) and agree to comply with SUNY Potsdam policy and state and federal regulations
regarding the use of human subjects in research. I further agree to execute this project as described in this
proposal; request approval from the IRB for changes; submit applications for continuation of approval as
required; submit a final report at the conclusion of the study; and be responsible for the supervision and work of
my staff and/or students.
________________________________________________________
Signature of Principal Investigator
Johanne Sullivan, Chair
Raymond Hall 204
Phone 267-2688
__________________
Date
SUNYPotsdamIRB@potsdam.edu
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STATE UNIVERSITY OF NEW YORK AT POTSDAM
INSTITUTIONAL REVIEW BOARD
List each Co-investigator, staff member or student involved in the study who will have contact with
subjects or raw data. They must also complete an Appendix B – unless this a classroom project. If this is
a classroom project students must then complete Appendix F instead of Appendix B.
Co-Investigator
Student
Staff:
Co-Investigator
Student
Staff:
Co-Investigator
Student
Staff:
Co-Investigator
Student
Staff:
Provide a summary of the research project that provides a clear justification for the project’s exemption
from IRB review. The summary must include at least the following:
A description of the intended subjects. In particular, note whether individuals belonging to any vulnerable
populations (such as individuals under the age of 18) will be included in the study.
A description of what subjects will be asked to do and/or the nature of the data that will be collected from or
about subjects.
An indication of whether information will be collected or recorded in such a way that subjects can be
identified and, if so, how subjects will be identifiable. Note any measures that will be taken to insure the
confidentiality of data. *Note: if electronic solicitation is used you must complete Appendix G and submit
it to the office of Institutional Effectiveness for approval:
A description of any risk to subjects and how that risk will be minimized. Note whether any of the risks
exceed minimal risk.
Include any other information that you feel is a factor in determining whether this research qualifies for
exemption:
Johanne Sullivan, Chair
Raymond Hall 204
Phone 267-2688
SUNYPotsdamIRB@potsdam.edu
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