Student Affairs Research Approval Form
In an effort to reduce survey fatigue the Office of the Dean of Students requires that all research on University of Illinois
at Urbana-Champaign students to be registered with our office. Please complete this form and attach all
documentation.
Today’s Date:
Principal Investigator:
Email:
UIUC Unit or Other Institution:
UIUC Campus Address or Complete Mailing Address if non-UIUC Institution:
Phone:
TITLE OF RESEARCH PROJECT:
Expected dates of study administration
Type & number of students to be solicited to participate
Will data be used ONLY for internal purposes by your department or unit? Yes
No
If yes, attach a copy of your notice of exemption from IRB and a copy of your study protocol stipulating methodology and any
instruments. If no, please seek IRB approval.
All non-UIUC entities are required to submit their institutions’ IRB approval or letter of exemption.
Have you prepared an Institutional Research Board request?
Yes
No
If yes, PLEASE ATTACH A COPY OF ALL THE IRB FORMS and skip questions 1-3.
See: http://www.irb.illinois.edu/ for UIUC IRB information. Send a copy of the approval or exempt notice once it is available.
1) COST
a.
To Student (e.g., time; inconvenience; monies/fees, etc.)
b.
To Principal Investigator (e.g., what/who are your supporters/funding sources?)
c.
To Unit/Department/Division of Student Affairs (e.g., space; professional/secretarial staff time; supplies; and
other resources used initially and ongoing)
UIUC Student Affairs Research Approval Form
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2) BENEFITS
a.
To Students (e.g., how does this research assist students in achieving their educational objectives; remove
barriers to education; promote retention; enhance personal development, etc.?)
b.
To Principal Investigator (How will the research be utilized? E.g., meet degree or course requirements; publish
results; evaluation of a unit or program, etc.)
c.
To Unit/Department/Student or Academic Affairs (e.g., enhance the quality of service or program delivery;
create more cost effective modes of services/program delivery; meet Strategic Plan goals; expand the body of
professional knowledge; document best practices; develop expertise, etc.)
3) WHO HAS BEEN CONSULTED ABOUT THIS PROJECT?
Please Provide Original or Electronic Signatures: (E.g.,
an electronic signature.)
Typing in a name is not considered
________________________________________________________________________________________________
Principal Investigator
Date
________________________________________________________________________________________________
Principal Investigator’s Supervisor (Required if PI is a student/otherwise optional)
Date
________________________________________________________________________________________________
Additional Researcher(s) (if any)
Date
________________________________________________________________________________________________
Additional Researcher(s) (if any)
Date
Student Affairs Approval by
Chair, Student Affairs Research Committee, Dean of Students, & Associate Vice Chancellor, Kenneth T. Ballom
Date
This form will not be processed until complete which may delay your study.
Questions and/or this form should be submitted to Dr. Belinda De La Rosa, 300 Turner Student Services building,
blarosa@illinois.edu, (217) 333-0050.
UIUC Student Affairs Research Approval Form
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