The University of Western Ontario ~ Research Ethics Boards
Request for Approval of an Undergraduate Course-Based Research Project
Document: 1-F-001 Version: January 2004
Page 1
Complete this form if you are a course instructor and you wish to oversee the conduct of undergraduate student research,
in accordance with the UWO Guidelines for Ethics Review of Undergraduate Course-Based Research Projects
Involving Humans (Please review the Guidelines prior to completing this form).
Submit three copies of this form, together with all attachments to either your Departmental or Faculty Sub-REB or the
Office of Research Ethics, Room 00045 Dental Sciences Building .
1
2



Course Instructor
Name
Title & Position
Degrees
Departmental
Affiliation
Mailing Address
Telephone
Email
Fax
Signature of Course Instructor attesting that they:
have reviewed the UWO REB Guidelines for Ethics Review of Undergraduate Course-Based Research
Projects Involving Humans and agree to comply with the requirements of those guidelines and to ensure
that all student projects will fit within the criteria for course-based student projects.
are familiar with and agree to abide by the ethical guidelines and policies of The University of Western
Ontario, the Tri-Council Policy Statement: Ethical Conduct of Research Involving Humans, and those of
their profession or discipline.
will meet with the student investigators to monitor the research progress and will be available, should
problems arise during the course of the research, to supervise the students and assist in solving such
problems.
______________________________________
Signature
______________
Date
6a
COURSE NAME and NUMBER
DEPARTMENT OR PROGRAM
Indicate the academic terms that you want this
ethics approval to cover.
Has an Approval for a Undergraduate Course-Based Research Project been obtained for
this course on any prior occasion?
IF YES – complete 6a – 6d
Name of Instructor who received approval
6b
6c
6d
Name of Course if different from above
Ethics Board which issued the approval
Date of the Approval
3
4
5
6
YES
NO
The University of Western Ontario ~ Research Ethics Boards
Request for Approval of an Undergraduate Course-Based Research Project
Document: 1-F-001 Version: January 2004
Page 2
7.
Give a brief description of the type of research required in the course. [Attach a copy of the
course outline, which should include a section on ethical research involving humans, and a
reference to the Office of Research Ethics web site. http://www.uwo.ca/research/ethics/ ]
8.
Provide a copy of the instructions that will be given to the student researchers. These
instructions should include the following information:
a.
b.
c.
d.
e.
The purpose of the project;
recruitment method including relationship of participants to the student researchers;
procedure for obtaining participants’ consent;
procedure for dealing with participants who wish to withdraw from the research project;
the debriefing procedure (i.e. How the participants will be informed of the results of the
research, if applicable.);
f. provisions to establish data confidentiality, if applicable;
g. a statement confirming that all projects to be conducted must involve less than minimal risk
to the participants and that they must fall within the criteria outlined in the “Guidelines for
Ethics Review of Undergraduate Course-Based Research Projects Involving Humans”.
9.
Indicate the procedures or methodologies that will be utilized by the students for
data collection. (E.g. action research; interviews, focus groups, questionnaire, etc. )
10.
Attach a copy or a model of the following materials where applicable:
a.
b.
c.
d.
The data collection instrument(s) that will be utilized;
The consent form and / or letter of information / transcript of telephone script;
Recruitment materials / posters;
Any debriefing materials which will be utilized by the students.