Protocol #
Application for Research
Involving Human Subjects
(admin use only)
EM from PI
HS Research Protocol: All research projects, involving human subjects, regardless of funding source
EM from FA
must submit an application for review and approval by the Institutional Review Board (IRB) or the
Psychology Departmental Human Subjects Review Board (DRB) prior to the initiation of the research.
Completed applications must be emailed as attachments to [email protected]. If you have questions, contact the
Office for the Advancement of Research and Scholarship: (513) 529-3600.
A. Personnel Information:
Primary Investigator(s):
Faculty
Staff
PRIMARY INVESTIGATOR: Name, Department, UniqueID (ex: smithja),
Graduate
Undergraduate
CITI online training date,
MU Application Training Date
Name
Email address: [email protected]
Campus or Postal Address(es):
enter address
Phone:
(513) 529 -
Other project personnel who will interact with subjects or data (CO-PI’s, research assistants, etc.)
List Names, UniqueID, and Date completed CITI online training (add lines as necessary)
Names, training information
FACULTY ADVISOR (for student PI’s): Name , Department, UniqueID, CITI online training date, MU Training Date
Enter faculty advisor information
Faculty Advisor email address: [email protected]
B. PROJECT INFORMATION:
Project Title:
Enter Project Title
Human Subjects
Research Dates:
Funding Source:
Projected beginning date: mm dd yy (e.g. Jan 01 09)
Projected ending date: mm dd yy
(and after IRB approval)
If externally funded, enter OARS
eSPA ID
eSPA ID number:
C. Does this project make use of any of the following special types of subjects and/or locations?
(check all that apply)
Children
International Research
Elementary and Secondary Schools
Prisoners
Pregnant Women and Fetuses in Utero
Research in VA Hospitals
Research Conducted with Clinical Populations in which HIPPA Applies (e.g. medical, psychiatric)
*In the online CITI Training Program there are training modules associated with each of the above special cases. You will need to
complete any of the checked associated modules, if not listed in the required modules.
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D. Answer these six true-false questions to the best of your ability (or leave blank if unsure) :
(The answers to these questions will aid the reviewers in determining the type of review conducted)
T
F
Subjects are over 18 years old.
T
F
Research does not focus on subjects that are pregnant, prisoners, or
economically or educationally disadvantaged.
T
F
Risk of harm is not reasonably greater than normal everyday life. Note: risk categories
include physical, emotional, psychological, social, economic, legal etc.
T
F
The data was collected by someone other than the personnel listed above before the research was
planned and identifiers were removed or were never recorded before Miami personnel had
access to the data.
T
F
The research uses normal educational practices in a normal setting: e.g. evaluating
established educational techniques, curricula, or classroom management
T
F
The research is initiated by program leadership to evaluate a public benefit program where
evaluation or improvement of service quality is the objective and methods to gauge this
do not include interviews/surveys that pose a risk greater than normal to those
interviewed or completing surveys.
E. INVESTIGATOR’S ASSURANCE STATEMENT
I have read Miami University's policy concerning research involving human subjects and by signing below:
1. I agree to accept responsibility for the ethical conduct of research conducted in this project;
2. I agree to obtain approval from the Institutional Review Board or Departmental Review Board prior to
modifying any of the procedures;
3. I agree to submit an Application for Approval of Continuing Projects describing the current status
of the project as specified in the approval letter;
4. I attest that the information submitted in this application is true to the best of my knowledge.
Students: send your application to your faculty advisor.
Faculty: submission by attachment using your MU email address
to [email protected] serves as your signature and pledge to abide
by the conditions stated above. This cover page document should be sent in
its current format (not scanned), no original signatures are required
Primary Investigator Signature _____(Submitting by MU email serves as your signature) _____ Date: mmm dd yy
Faculty Advisor Signature _____(Submitting by MU email serves as your signature) _____ Date: mmm dd yy
Notes: (for administrative use only):
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