IRB – Request for Review - Hannibal-LaGrange University

Name*

First Middle Last

Email*

Student Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title of Classroom Action Research Project*

Advisor's Name*

Advisor's Email*

Start Date (if approved)*

Anticipated End Date*

Tell Us About Your Project

Use one or two sentences to answer each question below.

Summarize the nature and purpose of your research project

A. Who are the subjects and how many will be involved in the project?

B. How will you recruit/select the subjects, or how will you gain access to them?

C. For how long (number of occasions and duration) will each subject be involved in the project?

D. If the subjects are students, what is the name of the institution in which they are enrolled? (You must submit letters of approval from any/all schools involved)

E. How will you protect the subjects' confidentiality in your study?

F. What are the possible risks to the human subjects? What precautions will be taken to minimize these risks?

G. What are the anticipated benefits (individual, institutional, or societal) to be gained by completing the project?

H. How will the information derived from this activity be used? To whom will the information be distributed

I. Informed consent must be obtained from the subjects, or in the case of children under 18, the parent or legal guardian. Have you attached a copy of the Informed Consent Agreement that includes all the elements listed on the checklist accompanying this form?

Yes
No

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J. Are you obtaining from your subjects information about their private behavior, economic status, sexual preferences, religious beliefs, or other matters which, if made public, might impair their self-esteem or reputation, or could reasonably place the subjects at risk of criminal or civil liability or be damaging to their financial standing or employability?

Yes
No

If you answered yes to the above question, describe how you will ensure that all your data are kept secure and confidential until they are destroyed.

I certify that the statements made in this request are accurate and complete. If I receive IRB approval for this project, I agree to inform the committee, in writing, of any problems or proposed procedural changes. I further agree not to proceed in the research until the problems have been resolved or the IRB has reviewed and approved the changes.*

If you agree, type your name in the box as an electronic signature.

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