Human Subjects Approval Request

I. General Information

Title of Study*

Project starting date*

Project ending date

Principal Investigator*

Mailing Address*

Street Address City State ZIP Code

Phone*

Email*

Co-Investigator(s)

Funding Source

Faculty/Advisor/Sponsor

Department or School

(if Applicable)

Review Type Requested*

For more information, see item 5 in this One Stop Solution. If this request is a Revised Submission, please include original request form.

II. Research Description

Statement of the research problem*

Number, type of participants/sample¹ and special characteristics.²

Number	Type of Participant/Sample	Special Characteristics	Actions

There are no Entries.

Will participants receive any type of compensation for their participation?*

Describe the compensation

Do the participants belong to any of the following protected populations?

Check all that apply.

Minors (17 or younger)
Individuals who are cognitively impaired or unable to give consent
Prisoners
Pregnant women and fetuses
Any individual who might not be capable of making an informed decision concerning participation e.g.., persons with mental illness or psychiatric disability, economically disadvantaged, educationally disadvantaged.

Using participants from any of the above categories requires submission of HSAR II.

Will deception be involved?*

If “Yes” submit HSAR II.

Does the study involve any sensitive topics that might adversely affect the participant’s reputation, character, or employment (e.g., sexual or illegal behaviors)?*

If “Yes” submit HSAR II

Sequential Outline of Procedures*

III. Data Collection

Instruments:

List and attach all tests, questionnaires, interview protocols, observation schedules, etc. and list the type of subjects to whom each will be applied (See II. B. for types and characteristics):

Instrument	Type of Subject(s)	Actions

There are no Entries.

Methods of collecting the data*

Is confidentiality insured*

If “Yes” please specify how you will handle confidential data during and after your study: If “No” explain:

Confidentiality Explanation*

Attach copies of any instruments used and informed consent statements or forms.

Drop files here or

Max. file size: 12 MB.

¹ Type: student, teacher, faculty, administrator, etc.
² Special Characteristics: achievement levels, socioeconomic status, exceptionalities, neighborhoods, etc.

Phone

This field is for validation purposes and should be left unchanged.