ࡱ> HKEFG "bjbjhh 4N g gGQbxx8Th\=??????$h c"cxx3xRx8==`@CRk)0!F!!\cc3!X >:  IRB APPLICATION FORM Application must be typed. Use additional space as necessary. 1. NAMES, PHONE NUMBERS, AND EMAIL ADDRESSES OF RESEARCHERS: (If there is more than one researcher, indicate one as the Principal Investigator. This will be the person the IRB contacts.) 2. HOME AND EMAIL ADDRESSES: (Homes addresses must be physical addresses. Student researchers must provide a campus address or an In Care Of address of their Research Supervisor. Email addresses for logo faculty or students must be Keystone email accounts.) (Student researchers may omit #3-4, unless they work on campus.) 3. PLACE OF EMPLOYMENT: 4. POSITION OR JOB TITLE: WORK PHONE: 5. TITLE OF STUDY: 6. Study is: (a) Thesis_____ (b) Dissertation______ (c) Other (specify)_________________________ 7. Does your research have a potential or actual financial interest of any kind (e.g., any form of payment for services, equity interests, intellectual property rights, etc.)? ___ Yes (Please complete the Financial Conflict of Interest form at the end of the IRB application and submit with the application.) ___ No 8. Name of advisor/class professor (if applicable): Department or Program: Phone: 9. Anticipated starting and completion dates: 10. What is the purpose of the study? 11. What are the hypotheses or research questions? 12. Explain your qualifications for conducting this research. 13. Explain the rationale and significance of the study. 14. Describe the subjects, removing geographic identifiers that could compromise anonymity or confidentiality. Age(s) of subjects: _________________________________ Number of subjects: __________________________________ 15. From where and how will potential subjects be identified (e.g., outpatient list, class list, etc.)? (If you are recruiting subjects from logo classes, you must specify which instructors have given permission and emails or signed letters from those instructors must be attached. If you are recruiting logo athletes, you must also have the permission of the Athletic Director and any relevant coaches, and emails or signed letters from them must be attached.) How do you have access to this population? (If you are recruiting from logo classes or athletes, you must inform the Student Government Association by sending an email to studentsenate@keystone.edu.) Has the Student Government Association been informed of this project? _____Yes Date______________________ 16. Do you have a supervisory and/or professional relationship with the subjects? (Student researchers should disclose positions such as Resident Assistant.) _____Yes _____No If yes, please explain how this relationship will not compromise the voluntariness of the subjects participation in the study. 17. Will data be collected from or about any of the following protected populations: NOTE: IF YOU ARE CONDUCTING YOUR RESEARCH SOLELY VIA A SURVEY, CHECK BELOW AND MOVE ON TO ITEM #18. ______ SURVEY ______ minors (under 18 years of age; specify age) ______ prisoners ______ pregnant women ______ fetuses _____ cognitively impaired persons For additional requirements regarding these categories of protected subjects, consult and follow the IRB Guidelines. 18. What are your criteria for subject selection? (Selection of subjects must be equitable and, in the case of protected populations (see #17 above), should reflect their special needs. IRB Guidelines also require researchers to be sensitive to the use of educationally and economically disadvantaged persons as subjects. If you are excluding women or minorities from your subject pool, you must include a scientific justification for such exclusion.) 19. How will subjects be recruited once they are identified (i.e., mail, phone, classroom presentation)? (Attach copies of recruitment letters, flyers, or advertisements, or copy of script or oral request at time of recruitment.) 20. Where will research be conducted? (Be specific.) 21. Will deception be used? _____Yes _____No If YES, provide rationale for the deception: 22. Please explain debriefing procedures, if any, to be used in this study. 23. What methodology will be taken to insure the anonymity of the subjects and the confidentiality of the data (i.e., coding system, how and where data will be stored and secured, how data will be analyzed, who will have access to data, what will happen to data after the study is completed)? If data is going to be stored electronically, what technology (i.e., firewalls) and software are being used to ensure confidentiality? Cite the strength of these. Note that researchers (or their supervising instructor) should retain all data collected (including any audio or video recordings) for at least 3 years after project completion. 24. Is a subject follow-up anticipated? _____Yes ______No If Yes, for what reason? 25. Describe the design and methodology, including all statistics, IN DETAIL. What exactly will be done to the subjects? In addition, specify if there will be any AI (artificial intelligence) used in either generating data or analyzing data. If AI is used, explain how it will not adversely impact the participants. ( Include what statistical tests will be used. Explain specifically what surveys, physical tests, observations will be used. Give details about exactly what the participants will be asked to do.) 26. Explain how the methodology and design fit the hypothesis/research question. 27. Give power analysis to justify number of subjects. 28. Give reliability, validity and norming information on all instruments. 29. Describe any equipment that will come in contact with the subject. Brand name and model, as well as description of its function. If electrical equipment is connected directly to the subjects, as with GSR and EFF measures, assurances concerning the safety of the equipment (technician should certify that equipment was checked within the last month) should be included. 30. 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