Irb Cover Sheet

INSTITUTIONAL REVIEW BOARD COVER SHEET FORM APPLICATION CATEGORY EXPEDITED

FULL REVIEW

MODIFICATION PROTOCOL #___________

TYPE OF RESEARCH Graduate

Undergraduate

Faculty

Other, Specify

________________

PRINCIPAL INVESTIGATOR ________________________________________________________________________________ FACULTY STAFF STUDENT PROJECT TITLE __________________________________________________________________________________________ __________________________________________________________________________________________________________ PROPOSED PROJECT PERIOD:

From __________________________

To: ________________________________

MAILING ADDRESS: _______________________________________________________________________________________ E-MAIL:____________________________ PHONE:____________________________ __________________________________________________________________________________________________________ NAME OF RESEARCH ADVISOR (if student): ___________________________________________________________________ E-MAIL:____________________________________ OUTSIDE AGENCY INFORMATION NAME OF INSTITUTION COLLECTING DATA:_________________________________________________________________ ADDRESS:_________________________________________________________________________________________________ PHONE NUMBER OF PRINCIPAL INVESTIGATOR:_____________________________________________________________ SPONSOR INFORMATION GRANT SUPPORT/FUNDING

YES

NO

If yes, budget amount $_______________________________________

NAME OF FUNDING AGENCY:_______________________________________________________________________________ RESEARCH METHODS AND PARTICIPANTS Questionnaire/Survey Internet Survey

Interview Test

Task

(Please check all that apply)

Data Banks Other

Videos

Recordings

Files

Observation

___________________________________________

PARTICIPANTS (BE SPECIFIC):_____________________________________________________________________________ NUMBER OF EXPECTED PARTICIPANTS: _____________________________

SIGNATURE OF PRINCIPAL INVESTIGATOR __________________________________ DATE _________________________ SIGNATURE OF FACULTY ADVISOR For Office Use Only:

APPROVED

__________________________________ DATE _________________________ RESUBMIT WITH MODIFICATION

DENIED

COMMITTEE SIGNATURE:____________________________________________________________________DATE__________