ࡱ> HKEFGc %bjbj v؎U\؎U\|8&< < $P(<d sbpb("((()|4, @-```````$Wd g`e-))--`((4-b000-F((`0-`00U. \( U.jY*`Cb0sbY"gx.0gT \ \g\p--0-----``/0---sb----g---------< > z:  Directions for Completion of the IRB Application Form Handwritten forms will not be accepted. Check boxes by double clicking on the box ! then choose checked! then click  OK . Words within the form that appear blue and are underlined are hyperlinks. Clicking on these words will direct you to a web page that provides more information on how to fill out that section of the form. A check list of necessary items is provided for your convenience on the last page of this form. Also, on the last page of this form are further instructions and additional information regarding the IRB process. Please submit the Application for Review of Human Subjects Research to the IRB office as a single sided document. When submitting via email a scanned copy of the signature page is required. Application for Review of Human Subjects Research Submitted to the jackson state university Institutional Review Board Pursuant to 45 CFR 46 ________________ Date Received Type of Review:  FORMCHECKBOX  Exempt  FORMCHECKBOX  Expedited  FORMCHECKBOX  Full Board Protocol #:  FORMTEXT       FOR OFFICE USE ONLY Title of Project:  FORMTEXT       Research Project Period:  FORMTEXT       to  FORMTEXT       Month/Year Month/YearIs the Project externally funded?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, complete the following:  FORMCHECKBOX Private  FORMCHECKBOX State  FORMCHECKBOX Federal Agency:  FORMTEXT       Grant No:  FORMTEXT       JSU Routing No:  FORMTEXT       Site of Research:  FORMTEXT       (If a cooperating institution, i.e., school, hospital, prison, etc. is involved, prior written permission must be obtained. (Append approval letter.) Faculty/Advisor/Researcher(s): I acknowledge that this represents an accurate and complete description of my research. If there are additional faculty, provide information on the additional faculty continuation page form located on the JSU website. FORMTEXT        FORMTEXT        FORMTEXT       Faculty/Researcher(s) Name (typed) Signature of Faculty/Researcher Date  FORMTEXT        FORMTEXT       Department College/School  FORMTEXT        FORMTEXT        FORMTEXT       Faculty/Researcher(s) Mailing Address Phone E-Mail (JSU only) HYPERLINK "http://www.citiprogram.org/"Required CITI Training Complete:  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Training must be completed before application can be reviewed) Cite Your Research Experience:  FORMTEXT       Staff: I agree to provide the proper surveillance of this project to ensure that the rights and welfare of the human subjects are properly protected.   FORMTEXT        FORMTEXT        FORMTEXT       Staff s Name (typed) Signature of Staff Date  FORMTEXT        FORMTEXT       Department College/School  FORMTEXT        FORMTEXT        FORMTEXT       Staff s Mailing Address Phone E-Mail (JSU only) HYPERLINK "http://www.citiprogram.org/"Required CITI Training Complete:  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Training must be completed before application can be reviewed) Cite Your Research Experience:  FORMTEXT        Student: I agree to provide the proper surveillance of this project to ensure that the rights and welfare of the human subjects are properly protected. (Must have faculty advisor to conduct research) Student Classification: (Please check) Anticipated Graduation Date:  FORMTEXT        FORMCHECKBOX  Doctoral  FORMCHECKBOX  Post-Doctoral  FORMCHECKBOX  Specialist  FORMCHECKBOX  Masters  FORMCHECKBOX  Undergraduate  FORMCHECKBOX  Other Project Purpose:  FORMCHECKBOX  Dissertation  FORMCHECKBOX  Thesis  FORMCHECKBOX  Class Project  FORMCHECKBOX  Other (explain  FORMTEXT       )   FORMTEXT        FORMTEXT        FORMTEXT       Student s Name (typed) Signature of Student Date  FORMTEXT        FORMTEXT       Department College/School  FORMTEXT        FORMTEXT        FORMTEXT       Student s Address Phone E-Mail (JSU only) HYPERLINK "http://www.citiprogram.org/"Required CITI Training Complete:  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Training must be completed before application can be reviewed) Cite Your Research Experience:  FORMTEXT       Additional Researcher(s)/Investigator(s): I agree to provide the proper surveillance of this project to ensure that the rights and welfare of the human subjects are properly protected.   FORMTEXT        FORMTEXT        FORMTEXT       Investigator s Name (typed) Signature of Investigator Date  FORMTEXT        FORMTEXT       Department College  FORMTEXT        FORMTEXT        FORMTEXT       Investigators Mailing Address Phone E-Mail (JSU only) HYPERLINK "http://www.citiprogram.org/"Required CITI Training Complete:  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Training must be completed before application can be reviewed) Cite Your Research Experience:  FORMTEXT        NOTE: If sufficient space is not provided below for a complete answer, please use additional pages as necessary. 1. Describe the purpose and the research problem in the proposed study. Your response in this section will enable the reviewer(s) to determine whether the project meets the criteria of research with human participants and also the extent to which the research may produce new generalizable knowledge that may benefit the participants and/or society.  FORMTEXT       2. Describe your research design:  FORMTEXT       a. Type of Research (please check):  FORMCHECKBOX  Qualitative (nominal or ordinal)  FORMCHECKBOX  Quantitative (interval or ratio) b. Type of Data (please check):  FORMCHECKBOX  Primary (human subjects)  FORMCHECKBOX  Secondary (human subjects)  FORMCHECKBOX  Secondary (bio-specimen) (If using secondary data, please attach your source, i.e., letter of permission, etc.) c. A brief description of your proposed data analysis: (T-test, chi-square, correlation, ANOVA, MANOVA, Regression, Discriminant Analysis, etc.)  FORMTEXT       **If using secondary data, please proceed to Question 17** Description of subjects: Describe the sampling population:  FORMTEXT       Describe the subject selection methodology (i.e. random, snowball, etc.):  FORMTEXT       Describe the procedures to be used to recruit subjects. Include copies of scripts, flyers, advertisements, posters, and letters to be used:  FORMTEXT       How many subjects are expected to participate? Show results of power analysis/G*Power  HYPERLINK "http://www.gpower.hhu.de/en.html%20%20" http://www.gpower.hhu.de/en.html   FORMTEXT       Note: If you have not conducted a power analysis or determined the sample size needed for statistical significance (inadequate numbers), then you must state your study is a Pilot Study in the Title of your project What is the expected duration of participation for each segment of the sampling population? If there is more than one session, please specify the duration of each session:  FORMTEXT       Describe the calendar time frame for gathering the data using human subjects:  FORMTEXT       Describe any follow-up procedures planned:  FORMTEXT       (b) Will the research include vulnerable populations?  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And please provide assent/consent forms) Check all that apply  FORMCHECKBOX  Children (17 years and younger)  FORMCHECKBOX  Pregnant women  FORMCHECKBOX  Prisoners  FORMCHECKBOX  Mentally disabled Provide a detailed description of any methods, procedures, interventions, or manipulations of human subjects or their environment and/or a detailed description of any existing datasets to be accessed for information. Please indicate the physical location where the research will take place (if multiple locations, please provide descriptions, i.e. virtual, online, etc.)  FORMTEXT       Include copies of any questionnaires, tests, or other written instruments, instructions, scripts, etc., to be used. You must append a copy of questionnaires or test instruments. The survey instruments and/or questionnaires are:  FORMCHECKBOX  Self-designed  FORMCHECKBOX  Purchased- (included name of publisher and append proof of purchase)  FORMTEXT        FORMCHECKBOX  Published in a journal-provide citation and permission from the author to use the instrument  FORMTEXT       Please list by position any additional personnel (undergraduate assistants, graduate research assistants, members of the community) who will be involved in the recruitment or consent process or data collection and/or analysis.  FORMTEXT       Please list names, emails and telephone contact information.  FORMTEXT       9. Will the subjects encounter the possibility of stress or psychological, social, physical, or legal risks that are greater than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, please justify the need:  FORMTEXT       Please specify the types of risks:  FORMTEXT       10. Do you supervise, teach, or have direct contact with the participants you plan to recruit?  FORMCHECKBOX Yes  FORMCHECKBOX No (if yes, please explain  FORMTEXT       ).11. Will the subjects be deceived or misled in any way?  FORMCHECKBOX Yes  FORMCHECKBOX No (If Yes, please explain:  FORMTEXT      ) How is it made clear to the subject that they may withdraw at any time? (Use the language from the consent/assent form.)  FORMTEXT       b. How is it made clear to the subjects that they may refuse to answer any specific question that may be asked of them? (Use the language of the consent/assent form.)  FORMTEXT       12. Will information be requested that subjects might consider personal or sensitive?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, please explain:  FORMTEXT       13. Will the subjects be presented with materials that might be considered offensive, threatening, or degrading?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, please explain, including measures planned for intervention if problems occur.  FORMTEXT      14. Will any inducements/incentives be offered to the subjects for their participation?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, please explain:  FORMTEXT       15. Describe the process to be used to obtain the consent/assent/parental permission of all subjects (as appropriate). Who will seek the consent/assent/permission?  FORMTEXT       16. Describe the steps taken to minimize coercion or undue influence, and the method(s) to be used to document consent/assent/permission.  FORMTEXT       Please submit copies of all consent documents with your application 17. Describe the steps you will take to protect the confidentiality of the collected information, and how you will advise subjects of these protections during the consent process.  FORMTEXT       Include information on data storage and access FORMTEXT       If data will not be reported in the aggregate, please explain how the data will be reported.  FORMTEXT        All responsible parties for this data, i.e., faculty/advisor, staff, student, etc. agree(s) that: Raw data will be kept in a secure location until the information has been saved as data file for analysis. The raw data shall be retained for 3 years, and all records relating to this research shall be retained for 3 years after completion of the research. All records shall be accessible for inspection and copying by authorized representatives of the Institutional Review Board at reasonable times and in a reasonable manner. Site Location:  FORMTEXT       Office Location and Address:  FORMTEXT        FORMTEXT        FORMTEXT       Name of Faculty/Advisor Name of Student __________________________________ ________________________________ Signature Date Signature Date  Application Submission (must include the following if applicable): Checklist for application submission:  FORMCHECKBOX Author s permission to use survey instruments  FORMCHECKBOX Author s permission to use secondary data (if applicable)  FORMCHECKBOX Completion of required CITI certificate (HYPERLINK "../www.citiprogram.org"www.citiprogram.org)  FORMCHECKBOX Outline or script of information to be provided prior to subjects agreement to participate  FORMCHECKBOX Copies of flyers, announcements or other forms of recruitment  FORMCHECKBOX Informed consent/child assent/parental permission forms  FORMCHECKBOX Instrument(s) [questionnaire, survey, tests]  FORMCHECKBOX Cooperative Institution Approval Letters Submission Addresses: Mail or hand deliver to: IRB/Research and Federal Relations Jackson State University Administration Towers 6th Floor Jackson, MS 39217P.O. Box 17057 Jackson, MS 39217 Email Submission (Application must be signed):  HYPERLINK "mailto:irb@jsums.edu" irb@jsums.edu For assistance, please contact the IRB staff in the Division of Research and Federal Relations at 601-979-2931 or email  HYPERLINK "mailto:irb@jsums.edu" irb@jsums.edu.     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