RESEARCH ETHICS BOARD
REQUEST FOR INSTITUTIONAL APPROVAL
COMPLETE THIS APPLICATION IF YOU ARE AFFILIATED WITH ANOTHER INSTITUTION AND REQUIRE
APPROVAL TO CONDUCT RESEARCH INVOLVING NIPISSING UNIVERSITY STUDENTS, STAFF, FACULTY
MEMBERS OR USING NIPISSING UNIVERSITY FACILITIES.
For Administrative Use Only
Date Received:
Host Institution:
Date Approved:
Approval #
IMPORTANT PLEASE READ: All relevant sections of this form must be completed. Attached documents may not
be used instead of the standard form(s). Applications must be submitted by the deadline date noted on the
Research Ethics Board website, in order to be reviewed in that month and at least 8 weeks in advance of the
project start date. Allow 4 to 6 weeks for the Research Ethics Board to respond. Reviews are conducted
according to the principles and spirit of the Tri-Council Policy Statement: Ethical Conduct for Research Involving
Humans. Applicants are advised to familiarize themselves with this document.
Any personal information collected on this form will form part of the records held in the Research Services Office and will be used
to assist in the administration of your research program. A copy of this form may be reviewed by external parties in order to
meet legislative, audit and/or regulatory requirements. If you have any questions or concerns about the information collected,
please contact the Ethics Coordinator at 705-474-3450 ext. 4055.
1.0
APPLICANT (Principal Investigator)
THE TCPS 2 ONLINE TUTORIAL MUST BE COMPLETED PRIOR TO PROTOCOL SUBMISSION. Please visit
http://www.ethics.gc.ca/eng/education/tutorial-didacticiel/
Have you completed the TCPS2 tutorial:
YES - I have attached my Certificate of Completion
Please provide your permanent mailing
address (including postal code):
Department /Faculty
Name:
Address:
E-mail Address:
Telephone Number (daytime):
1.1
Title of Research Project:
Proposed Start Date of Research:
Proposed End Date of Research:
1.2
NAME AND CONTACT INFORMATION
Department
Co-Investigator(s)
Faculty Supervisor (in
the case of student
research)
1|Page
Institutional Authorization Jun2013
RESEARCH ETHICS BOARD
REQUEST FOR INSTITUTIONAL APPROVAL
COMPLETE THIS APPLICATION IF YOU ARE AFFILIATED WITH ANOTHER INSTITUTION AND REQUIRE
APPROVAL TO CONDUCT RESEARCH INVOLVING NIPISSING UNIVERSITY STUDENTS, STAFF, FACULTY
MEMBERS OR USING NIPISSING UNIVERSITY FACILITIES.
Please choose one of the following that pertains to you:
Faculty Researcher
Administrative Researcher
Undergraduate Student Researcher
Graduate Student Researcher
2.0 SIGNATURES
Principal Investigator Assurance:
I certify that the information provided in this protocol is complete and accurate. I understand that I
have ultimate responsibility for the conduct of the study, the ethics performance of the project, and the
protection of the rights and welfare of research participants. I agree to comply with the Tri-Council
Policy Statement and Nipissing University policies and procedures governing the protection of human
participants in research. I will not make changes to this protocol without notifying the REB of the
proposed changes and seeking its prior approval.
Signature of Principal Investigator
Date
Faculty Supervisor Assurance: For student applications
I have read this protocol and deem it to be complete. I understand if this application is incomplete it will
be returned to me and I will be responsible for ensuring its completion. The project is valid and
worthwhile. I agree to provide the necessary supervision of the student(s) and to make myself available
to the student(s) should problems arise during the course of the research.
Signature of Faculty Supervisor
Date
2|Page
Institutional Authorization Jun2013
RESEARCH ETHICS BOARD
REQUEST FOR INSTITUTIONAL APPROVAL
COMPLETE THIS APPLICATION IF YOU ARE AFFILIATED WITH ANOTHER INSTITUTION AND REQUIRE
APPROVAL TO CONDUCT RESEARCH INVOLVING NIPISSING UNIVERSITY STUDENTS, STAFF, FACULTY
MEMBERS OR USING NIPISSING UNIVERSITY FACILITIES.
3.0
FUNDING STATUS OF PROJECT
Unfunded
External Agency/Sponsor
SSHRC
NSERC
Period of Funding From:
Funded
CIHR
Applied for
Other (please specify):
To:
Comments (optional):
3.1
OTHER RESEARCH BOARD APPROVAL
Research conducted in different research jurisdictions must be reviewed by different bodies when they, or
their equivalents, exist. In all cases, review is still required by the REB within the researcher’s home
institution. Please provide a copy of the host/home institutions protocol, including
all attachments and REB approval(s) received to this application.
a)
Is this a multi-centred study (more than one institution is involved)?
(i) If Yes, name the other institution(s) involved.
Yes
No
b)
Is this project under review by any other institutional Ethics Board?
(i) If Yes, name the other institution:
Yes
No
PLEASE COMPLETE AND SUBMIT ONE (1) SIGNED ORIGINAL AS WELL
AS ONE (1) ELECTRONIC VERSION OF THIS PROTOCOL TO:
Ethics Coordinator
ROOM F309
ethics@nipissingu.ca
Fax: (705) 474-5878
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Institutional Authorization Jun2013