District Human Research Review Board
READ THE UNIVERSITY POLICY PROTECTING HUMAN RESEARCH SUBJECTS. http://www.valdosta.edu/grants/irb98a.shtml
Researcher
Information
Last Name, First Name: _________________________, __________________________
Phone: _______________________________
Email address: __________________________________
Mailing Address: ______________________________________________
______________________________________________
School, Grade(s), Subjects taught: ___________________________________________
Research Information
a. Research Title: ___________________________________________________________
________________________________________________________________________
b. Estimated Start Date: _______________, c. Anticipated End Date: ______________
d. Description of your research project and the procedures to be followed:
e. Describe the pool of research participants:
f. How will your participants be recruited? Please be thorough regarding selection and recruitment:
g. Do you believe the participants will experience and discomfort/risk?
Yes __ No __
If yes, please describe:
h. Do you anticipate that the research procedures could be emotionally upsetting?
Yes __ No __
If yes, please describe:
How will the participants be informed that they do not have to participate in the study, and that they may withdraw at any time with no penalty:
Describe how you will protect the confidentiality and privacy of the participants’ responses:
Will your research protocol involve any sort of deception?
Yes __ No __
If yes, please describe:
Does your research involve videotaping, audio taping or photography?
Yes __ No __
If yes, please indicate what media you will be using:
Describe how you will secure the tapes/photos during the research and what you will do with the tapes/photos when your research is completed:
Do you anticipate that the research may involve altering, changing, or varying from any current Colquitt County School Board or school-based policies?
Yes __ No __
If yes, please provide justification and description of variation:
___________________________________________________
(Signature)
Review Board
Research Project Approved
Research Project Approved pending the following:
Research Project Denied
____________________________________________________
(Signature – District Representative)