Request to Use Subjects from the Psychology 120 Subject Pool
IRB Project Number
Date
Risk Level
Experimetrix Number(s)
1. Title of experiment
2. List every person who will have contact with subjects, as well as their capacity (e.g.,
experimenter, assistant, or confederate). Attach an additional page if necessary.
FULL NAME
FAC/GRAD/UNDRGRD
CAPACITY/DUTIES
__________________________
____
____
____
_______________
__________________________
____
____
____
_______________
__________________________
____
____
____
_______________
__________________________
____
____
____
_______________
3. Attach an informed consent from that includes the Experimetrix number(s) and name.
4. Attach a typed description that you will post on the Experimetrix program. This description is limited to
250 characters. If you wish to use a more detailed description, you may refer potential subjects to a web
page. If you do so, include a printed version of the web page.
5. Attach a typed debriefing document (and script if you plan to debrief orally). NOTE: PSY 120 textbook
references must be updated each semester noting which text is used by each instructor. Current textbooks
and lists of instructors are available in the PSY 120 Experiment Coordinator's office.
This request is based on an experiment protocol which has previously been approved by the Department of
Psychological Sciences’ Human Subjects Advisory Group and by the Purdue University Committee on the Use
of Human Research Subjects and is considered to be in active status by that Committee. This experiment will be
conducted in accordance with all Federal, State, University, and Department procedures and regulations.
___________________________________________
Major Experimenter
___________________________________________
Principal Investigator (faculty member)
___________________________________________
Co-Chair, Human Subjects Advisory Group
Rev: 11/03/03
_______________________
Date