Form #8
Cover Page
Application #
(For REB use only)
(Please submit your application via e-mail to research@kwantlen.ca
)
Title of Project : Click here to enter text.
Principal Investigator : Click here to enter text.
Position : Click here to enter text.
Department : Click here to enter text.
Contact telephone numbers : Click here to enter text.
Email : Click here to enter text.
Other contact methods (optional): Click here to enter text.
Fax : Click here to enter text.
Pager : Click here to enter text.
Preferred address to receive correspondence and/or approval if other than email :
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Co-investigator(s) (Name, Position and Department): Click here to enter text.
Additional assistants and their roles : Click here to enter text.
4 key words : Click here to enter text.
Proposed Start Date : Click here to enter a date.
Proposed End Date : Click here to enter a date.
(Expect a minimum of 6 – 8 weeks for a response from the Research Ethics Board.)
Signature : ________________________________________________
January, 2012
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Principal Investigator : Click here to enter text.
Date: Click here to enter a date.
January, 2012
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Full title of research : Click here to enter text.
1. Describe the purpose of the research.
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2. Describe the research question or hypothesis to be tested if known.
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3. Describe the methodology of the research study/project .
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4. Describe the method(s) of recruiting participants .
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5. Describe the participant groups in this study .
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6. Will the study involve any potential risks to the participants? If so, please describe the risks .
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7. Describe your informed consent procedures where applicable. Include a copy of your informed consent with application. Where it is not applicable, explain why it is not, e.g. where one is studying the public activities of politicians who have agreed to publicity, consent is already given. (Be sure to consider all of the elements of the Requirement for Free and Informed Consent in the guidelines.)
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8. Where deception is used, please include your rationale and debriefing procedures .
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9. What provisions are made for informing participants, for follow-up with participants?
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10. How do you plan to handle the requirement of confidentiality and/or anonymity where applicable?
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11. Describe any potential conflict of interest of anyone involved in the research .
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12. Describe any provisions for compensation of participants if applicable .
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13. To what purposes will this research be put? Will it be published or presented to an audience outside Kwantlen?
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14. List any funders who are supporting this project.
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15. Please notify the REB when your research is complete. Please submit an annual succinct status report to let us know if there are any changes from what was described in this application.
This form must be resubmitted after approval if there are major changes to your study. See part C of the Kwantlen Polytechnic University policy on post approval monitoring. Major changes include changes in protocol, consent, risks, participant groups, recruitment, compensation, deception, confidentiality, anonymity, researchers involved, or other ethically sensitive matters. Please highlight changes on the resubmitted form.
Surveys, consent forms, letters of introduction, recruiting materials, posters, advertisements and anything related to a research project without a completed review and approval of the
Research Ethics Board should be withheld by the researcher from distribution until the final approval of that project by the board.
If your research project has been approved at another institution, please include the
Certificate of Approval.
Are you requesting Expedited Review :
Please Provide Your Rationale for Expedited Review: Guidelines for Application for Expedited
Review (.zip)
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Date : Signature :
January, 2012
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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
___________________________________________
Witness to Consent if Subject Unable to Read or Write
(Must be different than the person obtaining consent)
___________________
Date
___________________
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.
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