REQUEST FOR REVIEW OF RESEARCH INVOLVING HUMAN SUBJECTS

REQUEST FOR REVIEW OF RESEARCH INVOLVING HUMAN SUBJECTS

BY THE COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS

WINTHROP UNIVERSITY

Amended for Proposal Assignment for SCWK 330

Submit one copy with your paper

Researcher's Name_______________________________________________________________________

1. Title of Research________________________________________________________________________

______________________________________________________________________________________

2. Please explain the research protocol or methodology to be used.

_________________________________________________________________________________

(Attach additional pages as necessary)

Please be advised: The principal investigator is responsible for informing all members of the research team of the research procedures to be used.

Include as attachments to this request the following: 1) A copy of applicable survey instruments; 2) A copy of informed consent agreements; 3) Copies of any other mail to be delivered to respondents or subjects (e.g. cover letters, scripts of verbal instructions, etc.)

3. Please explain briefly but completely what tasks or activities the subjects in this research will be doing.

_________________________________________________________________________________

(Attach additional pages as necessary)

4. Please describe the target subjects for this research. Does the research involve subjects who are minors?

_________________________________________________________________________________

5. Please explain how subjects will be recruited for this research.

_________________________________________________________________________________

6. How will you assure that the participation of the subject is voluntary?

_________________________________________________________________________________

7. Can the human subject be directly identified by:

Name on response form _____Yes _____No

Photograph _____Yes _____No

Television/VCR-type tapes _____Yes _____No

Audiotape _____Yes _____No

Coded research forms _____Yes _____No

Other _____Yes _____No

(Please specify if other)____________________________________________________

8. Can the subject be identified through:

Detailed biographical data _____Yes _____No

Coded research forms _____Yes _____No

Other _____Yes _____No

(Please specify other)______________________________________________________

9. The researcher shall make every possible attempt to maintain confidentiality of the research and the human subjects. IF for some reason, the responses, information, or observations of the subject became known to persons other than the researchers, could this information reasonably place the subject at risk of:

Damage to his/her financial standing? _____Yes _____No

Damage to his/her present or future employability? _____Yes _____No

Criminal or civil liability? _____Yes _____No

Psychological/emotional problems _____Yes _____No

10. Are any of the techniques listed below involved in the research?

Invasive medical _____Yes _____No

Noninvasive medical _____Yes _____No

Strenuous exercise _____Yes _____No

Other physical testing _____Yes _____No

(Please specify if other)_____________________________________________________

I CERTIFY THAT THE ABOVE INFORMATION IS AN ACCURATE AND COMPLETE STATEMENT OF THE NATURE OF MY RESEARCH.

Signature of Researcher:___________________________________________ Date__________________

Committee for the Protection of Human subjects at Winthrop University, 1995

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