Lab Ad Form - Human Subjects Lab - University of California, Irvine

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UNIVERSITY OF CALIFORNIA, IRVINE
SOCIAL SCIENCE HUMAN SUBJECTS LAB POOL
HS Lab Pool Recruitment Ad Form
NOTE:
In order to use the HS Lab Pool for recruitment purposes, you must complete and submit this form to
UCI’s Institutional Review Board (IRB) for review and approval.
Submit this form as part of a new IRB application or as a modification to an existing approved protocol
via e-MOD at: http://apps.research.uci.edu/irmod.
When you receive IRB approval of this ad, please provide the approved and stamped copy of it along
with your other approved and stamped documents to the Social Science Lab Administrator at:
[email protected] For questions or more information about the HS Lab Pool, please visit
http://hsl.ss.uci.edu/ or contact the Lab at [email protected] or (949) 824-1023.
1. Lead Researcher Name and Department:
[type here]
2. Faculty Supervisor/Sponsor Name and Department:
[type here]
3. Study Title (Be sure that the name has not been used before):
[type here]
4. Short Title (Must be fewer than 20 characters):
[type here]
5. Description of Study (i.e., What will participants be asked to do? Describe in fewer than 1,000 characters):
[type here]
6. Selection/Eligibility Criteria (e.g., >18 years old, right-handed, male, female.):
[type here]
7. Exclusion Criteria (e.g., Must not have completed a certain experiment before):
[type here]
8. Time Commitment (Must be in ½ hour increments, e.g., 0.5 hours, 1.0 hours):
[type here]
9. Course Extra Credit Amount (e.g., 1/2 hour – ½ credit; 1 hour = 1 credit):
[type here]
10. Anticipated Benefits (if any):
[type here]
Updated: 09/2013
11. Location of Session(s) (Building and Room Number):
[type here]
12. Anticipated Dates and Times for Participation:
[type here]
13. Contact Name, UCI Department, Phone Number and E-mail:
[type here]
14. Emergency Cancellation Contact (Name, UCI Department, Phone Number and E-mail):
[type here]
Signature of Lead Researcher: ___________________________ Date: _______________
Please contact UCI’s Office of Research by phone, (949) 824-6662, by e-mail at [email protected] or at 5171
California Avenue, Suite 150, Irvine, CA 92617, if you are unable to reach the researchers listed at the top of the
form and have general questions; have concerns or complaints about the research; have questions about your
rights as a research subject; or have general comments or suggestions.
Updated: 09/2013
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