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Last saved by: Densont
Company: Savannah State University

SAVANNAH STATE UNIVERSITY
REQUEST FOR IRB REVIEW - Page One

Use this form to request review and approval of a new project before it is initiated.  Applications are to be typed or neatly printed (preferably typed).  Return all five completed application pages plus the completed checklist and include full details and all necessary documentation (letters of permission, questionnaires, interview schedules and questions, tests, informed consent statement, etc.)

Principal Investigator:      

SSU Department:      

Campus Address:      

Telephone Numbers:		SSU:      

				Home:      

Project Title:      

Co-Investigators (if any):      

Grant Information (if applicable):	☐ Planned	☐ Pending	☐ Funded

Supporting Agency:      

Proposed Project Period:      

I.	THE HUMAN SUBJECTS INVOLVED IN THIS RESEARCH:

	1.	Who are the subjects? (age, sex, range, etc.)      

	2.	How many subjects are involved?      

3.	How will you recruit or select the subjects?      

4.	How long will each subject be involved in the project? (number of occasions and duration)
	     				

REQUEST FOR IRB REVIEW - Page Two

5.	Where will the research project take place? (Enclose letter of permission when involving a cooperating institution, school, hospital, prison, business, etc.)     

Yes	No	(Please mark the appropriate column and provide details as necessary)

☐	☐	Will you advertise for subjects or post a notice for volunteers?  If YES, submit a copy of the
 advertisement notice.

☐	☐	Will you pay your subjects?  If YES, indicate how much and describe how you will pay subjects
who withdraw before the project ends?      

☐	☐	Are your subjects Savannah State University students?

☐	☐	Are your subjects students at an institution other than Savannah State University?  If YES, name
 		the institution(s) in which they are enrolled.      

☐	☐	Do you ensure appropriate representation of women and minorities in your project?

		Do your subjects include any of the following?

☐	☐	Infants and/or children younger than seven years

☐	☐	Institutionalized mentally impaired persons

☐	☐	Students enrolled in your own classes

☐	☐	Prisoners

☐	☐	Other special populations

II.	THE RESEARCH PROCEDURE/PROTOCOL
Describe in simple and concise terms, what you will be doing to or with your subjects? (Please include a lay summary of the project on a separate sheet).
     

REQUEST FOR IRB REVIEW - Page Three

Yes	No	(Please mark the appropriate column and provide details as necessary)

☐	☐	Will you obtain information about your subjects' private behavior, economic status, sexual
preferences, religious beliefs, or other matters, which, if made public, might impair the subjects' self-esteem or reputation?  If YES, describe how you will ensure that all your data are kept secure and confidential.      

☐	☐	Does your study involve deception of your subjects?*  If YES, describe how you will debrief
your subjects.      

☐	☐	In cases of deceptive research, are you willing to allow subjects to withdraw after debriefing and
remove from your data all records of your subjects' involvement?*

☐	☐	Will you be carrying out procedures or asking questions that might disturb your subjects
emotionally or produce stress or anxiety?  If YES, describe your plans for counseling and treating subjects.      

☐	☐	Will you use a questionnaire or structured interview as part of your procedure?  If YES, submit a
 		copy of the questionnaire(s) and/or interview questions.

*The SSU IRB does not approve of deceit in research.  It will review and may approve applications that involve limited deception, with the proviso that subjects receive a comprehensive debriefing.

Describe the final disposition of your data (notes, drafts, lists of subjects, photographic records, tapes, etc.) after
you have completed your research      

III.	REQUIREMENTS FOR INFORMED CONSENT

The Code of Federal Regulations governing research on human subjects (45 CFR 56.116) states that, "…no investigator may involve a human being as a subject in research covered by these regulations unless the investigator has obtained the legally effective informed consent of the subject or the subject's legally authorized representative.  An investigator shall seek such consent only under circumstances that provide the prospective subject or the representative sufficient opportunity to consider whether or not to participate and that minimize the possibility of coercion or undue influence.  The information that is given to the subject or the representative shall be in the language understandable to the subject or the representative.  No informed consent, whether oral or written, may include any exculpatory language through which the subject or the representative is made to waive or appear to waive any of the subject's legal rights, or releases or appears to release the investigator, the sponsor, the institution or its agents from liability for negligence."

Unless the IRB issues a specific waiver, the written informed consent of subjects is required for ALL research projects except those projects that qualify for certification of exempt status.  Written informed consent of subjects may also be required in some projects that qualify for certification or exempt status.  Written informed consent of subjects may also be required in some projects that otherwise qualify for exempt status.

REQUEST FOR IRB REVIEW - Page Four

Informed Consent for Minors
When research subjects will be under the age of 18, the written consent of one or both parents is required for projects for expedited or full board review, and for some projects that otherwise would qualify for exempt review.  Assent of the child may be required if the child is capable of making an informed decision whether or not to participate.

Storage of Informed Consent Forms
Signed copies of informed consent forms must be maintained by the principal investigator and be stored in a secure manner.  Furthermore, these files must be available for continuous review by the IRB.  If the investigator leaves Savannah State University before the end of the designated period for storage of forms, the files must be submitted to the OGSSR for final review.

Yes	No	

☐	☐	Is it clear to the subjects that their participation is fully voluntary?

☐	☐	Is it clear to the subjects that they may withdraw at any time?

☐	☐	Is it clear to the subjects that they may refuse to answer any specific question that may be asked 			them?

☐	☐	I will obtain written informed consent and I have attached a copy to be reviewed.  [I understand
 		if minors (individuals less than 18) are involved, parental consent will be required and included
 		in the informed consent].

Principal Investigator's Certification:

I certify that the information, statements, and all attachments provided in this request for IRB approval are accurate and complete, and if I receive IRB approval for this project, I fully understand my obligations to the human research subjects who will be used in my project.  I agree to use only the protocols reviewed and approved by the IRB for my research.  I also agree to submit the informed consent files for review every six months, during the progress of the project.  In the case of an occurrence of any unusual incidence or risk to the human subjects, I agree to inform the IRB immediately.

Principal Investigator's Name (Type or Print)      

															
Principal Investigator's Signature										Date

CHECKLIST FOR IRB APPLICATION - Page Five

☐		All questions have been addressed.

☐		Application has been typed or neatly written.

☐		If cooperating institution is involved, written permission is attached.

☐		The research design guarantees protection for research subject's rights.

☐		The research design ensures confidentiality of the data collection.

☐		The research design ensures anonymity of the participants, if appropriate.

☐		Each of the elements of informed consent is addressed.

☐	The informed consent statement is described in an understandable/appropriate terminology the potential subject can understand.

☐		A copy of the informed consent statement is enclosed.

☐		A copy of the testing instrument (survey, questionnaire, interview questions) is included.

															
Signature of Principal Investigator										Date

MODEL OF A STANDARD CONSENT FORM

Your consent form will be compared against the following model in order to meet federal requirements.

The following model of an Informed Consent Form contains all elements required by law, with instructions to assist you in the development of the consent form of your project.

CONSENT FORM

(YOUR PROJECT TITLE APPEARS HERE)

Invitation to Participate:  You are invited to participate in a study of 						 (describe what is to be studied) being conducted by					 (give names of investigators and their affiliations with SSU and other institutions involved).

Basis for Subject Selection:  You have been selected because 				 (state reasons why).  This statement should help the subject assess the nature and importance of participation.  When appropriate, state the approximate number of subjects involved in the study and any criteria for subject exclusion (e.g. pregnancy, age, limitations, health restrictions).

Overall Purpose of Study: Give a clear description in simple language of the overall purpose of the research.  This should help the subject assess the importance of the study relative to individual values.

Explanation of Procedures: If you decide to participate, you will be given the following tests or asked to do the following things:  These should include, where appropriate, the following:

a.	A description of the study design (e.g., longitudinal, single blind, placebo, quantitative, qualitative).

b.	A description of each procedure to be applied to human subjects and how often it will be performed.

c.	The identification of the individual(s) who will perform the procedures.

d.	A statement of where and when the research will be conducted, and how much time (per session and in total) will be required of the subject.

e.	A statement concerning any medications, therapeutic regimens, foods, or other substances that are contraindicated/disallowed either before or during participation in the study.

f.	If the research study involves incomplete disclosure or deception, all subjects must be debriefed as soon as possible after participation.  The consent form for nondisclosure/deceptive studies should normally contain a statement concerning when and where the debriefing session will be held.  If debriefing may be harmful to the subject, the investigator may request a waiver of the debriefing requirement.

Potential Risks and Discomforts:  Remember that the IRB will make the determination as to whether or not your project involves risks to the human subjects.  Risks can be classified generally, with some overlap, as:

1.	Physical -- e.g., infection associated with venipuncture or surgery, adverse reactions to drugs, heart attack induced by maximal exercise tests

2.	Psychological -- e.g., depression, confusion, feelings of guilt

3.	Social -- e.g., invasion of privacy, loss of community standard

4.	Legal -- e.g., criminal prosecution, revocation of parole

5.	Economic -- e.g., loss of employment, loss of potential monetary gain

Both immediate and later risks of any procedure must be clearly and adequately described, including the probability, severity, average duration, and reversibility of any potential injury.

Potential Benefits: Describe direct benefits, if any (e.g., improvement of health status).  If there are no direct benefits to the participants, explain the benefits that could result to others from this research (e.g., acquisition of knowledge).  It must be stated in the description that the benefits are hoped for (or anticipated), but not guaranteed by the investigator.

Alternatives to Participation: Describe alternative treatment, if any, if the prospective subjects are students who would participate in exchange for receipt or academic credit if he/she chooses not to participate.  The option(s) must be comparable to research participation in terms of time, effort and educational benefit.  This is not the same as "extra credit", which is a compensation for participation.

Compensation for Participation: If the subject will receive compensation, describe the amount or nature of the compensation (grade, credits, money, etc.).  The nature and amount of compensation must not constitute undue inducement to participate.

Assurance of Confidentiality: State that any information obtained that could identify the subject will remain confidential and will be disclosed only with the subject's permission.  If the investigator intends to release any information, the consent form must state persons or agency receiving the information, the nature of the information, the purpose of the disclosure, and whether the subject's name will be used as an identifier.  When appropriate, the ultimate disposition of data should be described.  Confidentiality safeguards must be especially strong where a breach of confidentiality may result in social or economic harm to the subject.

Statement of Injury or Special Costs: Describe any special costs to the subjects.

Withdrawal from the Study:  Your participation is voluntary.  You may answer any, all or none of the questions.  Refusal to participate carries no penalties.  If you decide to participate, you are free to withdraw your consent and discontinue participation at any time.

Offer to Answer Questions: You should feel free to ask questions now or at any time during the study.  If you have questions, you can contact:  (Give your name and phone number and the name and phone number of any co-investigator.  For research studies involving more than minimal risk, the home/night phone number of the investigator(s) must be provided.)  If you have any questions about the rights of research subjects, contact the SSU Chair of the IRB.

Consent Statement:

You are voluntarily making a decision whether or not to participate.  Your signature indicates that, having read and understood the information provided above, you have decided to participate.  You will be given a copy of this consent form to keep.

Signature of Subject						Date

															
Signature of Witness						Signature of Investigator

(The signature of a witness is required for all research studies involving more than minimal risk.  If possible, the witness should be someone who is not involved in the study.)