Cerritos College

Humanities and Social Science Division

 

 

IRB#:___________

 

Project title:________________________________________________________

 

Principal investigator:________________________________________________

 

Date received:__________

 

Date approved:_________

 

Changes to be made:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Approvals:                                                                  Date:

 

__________________________                                ______

(Dr. Darryl Beale)

 

__________________________                                ______

(Dr. William Dunroe)

 

__________________________                                _______

(Dr. Kimberley Duff)

FORM A

 

 

Cerritos College

Humanities and Social Sciences Division

 

Date received_________________                                                   IRB#__________

 

REQUEST FOR ETHICAL REVIEW OF AN EXPERIMENTAL PROJECT

 

  1. Short title:_____________________________________________________________

 

  1. Descriptive title:________________________________________________________________________________________________________________________________

 

  1. Principal investigator (PI):______________________________________

 

  1. Contact information:

 

Office___________          Phone_________________    Emergency______________

 

  1. All other investigators:

Name                                                   Phone

 

 

 

6.   Locations at which research is to be conducted:__________________________________________________________________________________________________________________________

 

 

  1. Funding source_____________________________________________________________________________________________________________________________

 

 

  1. Anticipated duration of protocol:  From __/__/__  TO__/__/__

 

9.  Will this study involve deception of human participants?  __yes  ___no

 

 

  1. Anticipated number of participants? _____________

Participants will include: (circle all that apply)

Cerritos students               Cerritos employees      Off-campus participants

 

 

 

  1. If you believe that your study does not require complete review, stop here and complete only form X.

 

  1. SUMMARY OF PROTOCOL: Please summarize your research protocol and attach to this form. You must address all of the following points.

 

  1. The objectives of this project (IV, DV and how they are operationalized;hypothesis being tested).
  2. The study method. Include the treatments, procedures or measurements on human participants. If this is a questionnaire study, include the instrument to be used.
  3. The inclusion/exclusion criteria for participants. Include the procedure to recruit participants and any advertising materials. Indicate payment to participants.
  4. Theoretical or potential risks and benefits to participants.
  5. Precautions and safeguards taken to insure the welfare of participants. Include method of assuring confidentiality.
  6. Potential gains for the participant.

 

  1. Informed Consent Statement and Debriefing form must be attached.

 

  1. I am familiar with Federal Regulations relating to Human Subjects research and with campus policies for this area of research, and I agree to abide by all pertinent regulations and policies.

 

I certify that the above information is correct:  ________________________________________

(Principle Investigator/Date)


FORM X  EXEMPT REVIEW STUDIES

(Only for experiments in which no manipulation/deception is involved)

 

 

NOTE: A copy of the proposal summary with objectives, background with pertinent references, methodology and significance, as well as samples of questionnaires to be used must be attached with this request.

 

 

 

PRINCIPAL INVESTIGATOR

 

Address:

Telephone:                                                                               Fax:

 

Name of Institution:

 

1. Title:

(Limit 60 spaces)

 

2. Site of research

(Where will research be conducted?)

 

3. Population and sample: (Estimate numbers and types of subjects to be used.)

 

___ADULTS ____MINORS)_____OTHER

 

4. Brief description of how subjects will be used. (Note: To qualify for EXEMPT REVIEW, subjects must be at no risk).

 

 

 

  1. Check one or more of the following research activities involving human subjects that qualify for EXEMPT review and approval. (Note: Subjects should not be identified in any category.)

 

____1. Research in common educational setting.

____2. Research using educational tests.

____3. Research involving survey or interviews except where respondents are minors.

____4. Research involving observations of public behavior except where interactions may occur with minors.

____5. Research involving study or use of existing specimens or data.

 

Principal investigator____________________ Date________________