COASTLINE COMMUNITY COLLEGE
Institutional Review Request Form
Research Study Involving Human Subjects
Principle Investigator:___John Boyd_______________________________________
Check one: ___ Faculty ___Staff
_X_ Undergraduate ___Graduate Student
Program/Department: Psychology 280 Research Methods Class Project
Person to contact regarding questions:_Dr. Amy Escobar_____________
Campus Telephone: _(714) 241-6251_ Campus Email:_aescobar@coastline.edu__
Project Title: __Do Women have Better Visual Memory than Men?____________
__________________________________________________________________
I. Check each of the following that are included in your research:
 Research on regular or special-education instructional strategies, curricula or classroom
management methods.
 Test, survey, or observational research in which the subjects cannot be identified, either
directly or indirectly, with their responses or information about them.
 Test, survey, or observational research in which the subjects can be identified, either directly
or indirectly, with their responses or information about them.
 Survey or observational research in which the subject’s responses or behaviors, if they
become known outside the research, could reasonably place the subject at risk of criminal or
civil liability or be damaging to the subject’s financial standing or employability.*
 Survey or observational research that deals with sensitive aspects of the subject’s own
behavior, such as illegal conduct, drug use, sexual behavior, or use of alcohol.
 Research involving the collection or study of existing data, documents, records, pathological
specimens, or diagnostic specimens which are not publicly available OR from which the
information is recorded by the investigator in such a manner that subjects cannot be
identified, directly or indirectly.
 Research involving the collection or study of existing data, documents, records, pathological
specimen, or diagnostic specimens which are not publicly available OR from which
information is recorded by the investigator in such a manner that subjects can be identified.*
 Research involving exercise by the subjects.*
 Research involving noninvasive procedure routinely used in clinical practice.
 Research involving voice and video recordings.*
 Research that will involve manipulating the subject’s behavior in a way that is stressful to
them.*
 Research involving minors (under 18).*
 Research involving subjects institutionalized as mentally disabled.*
 Research involving prisoners.*
 Research involving interviews.*
 Research involving questionnaires.*
 Research involving tests not normally used in educational or clinical settings.* Specify:
_____________________________________________________________
*These procedures generally require gathering Informed Consent from all participants.
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II. Investigator and other key personnel involved with human subjects on this project:
__John Boyd_____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
III. Description/Abstract. Provide 100-150 words stating the objectives and specific aims of the
research. Describe concisely the research design and methods for achieving these goals. Also
address issues such as:
 If the study uses participants in a school system, hospital, or other agency;
 The amount of time required of each participant;
 How, if at all, participants will be rewarded for participating;
 Methods of ensuing anonymity and confidentiality;
 Debriefing measures, if necessary;
 If and how feedback will be provided to the participants.
Abstract:
The purpose of this study is to determine if there are differences in memory by gender. It is
hypothesized that women will have better visual recall. After watching picture of everyday
objects (teakettle, dog, car, tree, etc.) the participants will be given a story to read. Half the
group will be given a story to read that has words in it related to the pictures they just saw
(“visual help group”). The other half will be given a “non-visual help story” to read. Males and
females will be assigned to the story groups randomly. It is hypothesized that women in the
“non-visual help” group will recall pictures better than men in either group. See attached
Research Description for the Institutional Review Board.
IV. Protocol. Include the research question or hypothesis, population selection (inclusion and
exclusion criteria), recruitment, study procedures and timetable, sample size determination,
outcome evaluation (i.e., measures, statistical analysis plan), safety review, criteria for stopping,
and anticipated accrual. Attach copies of any grant research plan/specific aims, survey
instruments, telephone scripts, etc. Attach this information to this form.
V. Accrual Information.
 Estimated number of participants to be screened: ____30______
 Estimated number of participants to be enrolled: ____20______
 Date of enrollment: Beginning: _one day this semester_ Ending: _same day__
VI. Risks. Describe potential risks to the study participants. Include physical, psychological,
emotional, and privacy issues. Outline what support will be available to participants experiencing
undesirable consequences of participations.
Describe: No more risk is anticipated than that typically involved in daily life. Participants will
merely be asked to look at pictures, read a story, and recall pictures. However, some
participants might experience performance anxiety or discomfort from sitting on an
uncomfortable chair for 30 minutes in a classroom-like setting.
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VII. Procedures to Minimize Risks. Describe:
There are no risks.
VIII. Benefits. Describe the potential benefits to the research participants and/or future mankind:
There are no potential benefits for the participant. It is hoped that the research will shed
light on any differences in the memory skills between men and women; those differences
might influence future research studies in many ways (e.g. aging and memory loss, college
student study, etc.).
XI. Assurance. The undersigned assure that the protocols involving human participants
described in this application are complete and accurate, and are consistent with applicable
protocols submitted to external funding sources. All protocol activities will be performed in
accordance with Coastline Community College, state, and federal regulations. No activities
involving the use of human participants will be initiated without prior review and approval by
the Institutional Review Board of Coastline Community College.
Project Title: _Do Women have Better Visual Memory than Men?____________________
________________________________________________________________________
___John Boyd_______________
Principle Investigator
____1/30/12____
Date
If Principle Investigator is a student:
_________________________________ __________________
Signature of Supervising Faculty
Date
_________________________________ __________________
Signature of Division Head
Date
Please forward a paper copy of the completed application to the appropriate review(s):
Student Projects must be reviewed by 1) the course advisor / instructor and by 2) the full IRB
membership.
Faculty Research must be reviewed by 1) the Department Chair and 2) the full IRB
membership.
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Institutional Research must be reviewed by 1) the Supervisor of Institutional Research and 2)
the full IRB membership.
External Research, conducted within Coastline Community College by organizations outside
Coastline Community College, must be reviewed by the full IRB.
COASTLINE COMMUNITY COLLEGE
Institutional Review Board Report
Project Title: _____________________________________________________________
________________________________________________________________________
_________________________________
Principle Investigator
_________________________________
Date
COMMITTEE RESPONSE:
______________________________ __________________ ___________________________
Signature
Date
Approve / Review Further / Deny
______________________________ __________________ ___________________________
Signature
Date
Approve / Review Further / Deny
______________________________ __________________ ___________________________
Signature
Date
Approve / Review Further / Deny
IRB Committee Comments:
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