Human Subjects Review Committee (HSRC)

Human Subjects Review Committee (HSRC)
Assemble materials in the order shown below.

0 1. Human Subjects Protocol
0 2. Human Subjects Certificate
0 3. Consent Forms
0 4. Instruments
0 5. College Approval of Research Proposal
(Only for Ed. D. program)

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HUMAN SUBJECTS REVIEW COMMITTEE (HSRC)
RECORD AND REVIEW OF RESEARCH PROTOCOL
Contact Information

Principal Investigator:

Address:

City: State: Zip Code:

Phone: Day Evening Cell

E-Mail: FAX:
Project Status

This research is for (check one):

Dissertation 0 Practicum 0 Master’s 0 Undergraduate 0

Other (specify)

This research proposal is (check one): New 0 Renewal 0 Re-evaluation 0

Instructor or assigned faculty sponsor:

Project Information

Title of Study:

Research purpose or issue:

Population to be studied:

Gender Age Race/Ethnicity

Number of groups and number of participants in each group:

Inclusion and exclusion criteria:

How subjects will be recruited:

Describe the procedures that the participants will undergo in the proposed research project to include the physical location and duration of subject participation (attach a copy of all research instruments (e.g., surveys, questionnaires, interview questions, etc.)):

Describe the procedures that will be used to maintain confidentiality, including plans for storing/disposing of tapes and other data records at the conclusion of the research:

Research Protocol (Please answer yes or no to all questions below)

Does this research involve:

YES NO
0
0
prisoners, probationers, pregnant women, fetuses, the seriously ill or mentally or cognitively compromised adults, or minors (under 18 yrs) as participants
0
0
the collection of information regarding sensitive aspects of the participants behavior (e.g., drug or alcohol use, illegal conduct, sexual behavior)
0
0
the collection or recording of behavior, which, if known outside the research, could place the participants at risk of criminal or civil liability or could be damaging to the participant’s financial standing, employability, insurability, or reputation
0
0
procedures to be employed that present more than minimal risk to participants
0
0
deception or coercion
0
0
benefits or compensation to participants
0
0