[Insert logo/letterhead]
DATA & RESEARCH REQUEST REVIEW WORKSHEET
Requester:
Request title:
Reviewers:
Original Date of Review:
Type of Request (check all that apply):
Data – Not confidential
Data – Confidential
Freedom of Information Act
Human Subjects Research
Type of Requester:
Military
Student – District Employee
Student – Non-District Employee
Other Researcher
Media
Partner
Other:
-----------------------------------------------------------------------------------------------------------------------------Review Committee Final Decision:
Incomplete application (may resubmit)
Not Approved
Approved as submitted
Approved with comments
Pending Approval with following corrections or modifications:
Signature: ________________________________________________ Date: ____________________
[Name and Title}]
Any changes made to the research, research procedures, or use of data requires the
submission of an addendum to the [district] for review.
DATA & RESEARCH REQUEST REVIEW WORKSHEET
Criteria
Applications should be evaluated according to the following overall criteria:
1.
Quality of the research:
 Quality of research is acceptable
 Quality of research is acceptable under the following conditions:
 Quality of research is not acceptable for the following reasons:
2.
Expected benefits to students, staff, and the district, including alignment with the goals and
objectives of the district
 Request does not further existing strategic goals or even detracts from focus; no benefit to
District
 Request is marginally aligned with strategic goals but would indirectly benefit District
 Request is in alignment with strategic goals currently identified by the District
3.
Potential risks and costs to staff, students, including conflicts of interest, and resources
required of staff, students, and the district
 Request involves an acceptable level of risk and cost to staff, students, and the district, as
follows:
 Request involves an unacceptable level of risk and cost to staff, students, and the district, as
follows:
Application Materials
All required forms should be completed in full and signed. Any form that is required and missing will
result in immediate rejection of the application; however, Requester can be notified in order to correct
the error.
1. Scope of Work (Required of all applications)
 Scope of Work is missing
 Scope of Work is approved as submitted
 Scope of Work is approved under the following conditions:
 Scope of Work is not approved for the following reasons:
2. Human Subjects Research Application
 Not applicable to this request
 Human Subjects Research Application is missing
 Human Subjects Research Application is approved as submitted
 Human Subjects Research Application is approved under the following conditions:
 Human Subjects Research Application is not approved for the following reasons:
[date]
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DATA & RESEARCH REQUEST REVIEW WORKSHEET
3. IRB Approval or Exempt Form
 Not applicable to this request
 IRB Approval or Exempt Form is missing or improper
 IRB Approval or Exempt Form is properly included
4. Instrumentation
All copies of measures are described and attached for review.
 Not applicable to this request
 Instrumentation is missing
 Instrumentation is approved as submitted
 Instrumentation is approved under the following conditions:
 Instrumentation is not approved for the following reasons:
5. Consent and Assent Procedures
All copies of letters and consents are described and attached for review. A thorough description of the
consent process is provided in the research proposal. Participants are notified of the risks, benefits and
other related study information to provide adequate description for informed consent.
 Not applicable to this request
 Consent Procedures are missing
 Consent Procedures are approved as submitted
 Consent Procedures are approved under the following conditions:
 Consent Procedures are not approved for the following reasons:
6. Confidential Information Access
Does requester have proper access to requested confidential data?
 Not applicable to this request
 Requester is conducting study for, or on behalf of schools, school districts, or postsecondary
institutions
 Requester is authorized representative of government institution to audit or evaluate a Federal- or
State-supported education program, or to enforce or comply with Federal legal requirements
 Requester is seeking parental consent for access to confidential data
 Requester is improperly seeking access to confidential data without fulfilling any of the conditions
above
7. Confidential Information Safeguards
Have sufficient security measures been described for the protection, storage and destruction of collected
data?
 Not applicable to this request
 Confidential Information Safeguards are missing
 Confidential Information Safeguards are approved as submitted
 Confidential Information Safeguards are approved under the following conditions:
 Confidential Information Safeguards are not approved for the following reasons:
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DATA & RESEARCH REQUEST REVIEW WORKSHEET
8. Will participants receive any incentives for participation?
 Not applicable to this request
 No incentives
 Incentives will be given and are acceptable
 Incentives will be given but are considered coercive for the following reason(s):
9. Reviewer Comments:
Note: This review worksheet was adapted from materials from the Providence Public Schools.
[date]
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