ࡱ> MPL C#bjbj .>ee 7 ...8f4<."nvgL, " " " " " " "$#&1"FggFF1"F"FR "F "r T !@Ƀ !\"0" L'nZL' !L' !0'"Ie1"1"T"FFFFL' : 91ܽ Institutional Review Board APPLICATION FOR EXEMPT CATEGORY REVIEW Project Title:__________________________________________________________________ A. Investigators: Faculty Investigator/Sponsor:_______________________________________________ Department:_____________________________________________________________ Campus:________________________________________________________________ Phone:___________________Fax:_________________Email:_____________________ Student Investigator:_______________________________________________________ Department:______________________________________________________________ Campus:________________________________________________________________ Phone:___________________Fax:_______________Email:_______________________ Address for Correspondence:________________________________________________ PLEASE ATTACH A SUMMARY OF THE PROPOSED RESEARCH: INCLUDE: Purpose of the study Statement indicating why study meets the guidelines for exempt review Subject population Brief description of procedures to be followed Brief description of risks and benefits to subjects involved in the study Recruitment Procedures Copies of consent forms, scripts, surveys, questionnaires, syllabi, and letters of cooperation should be appended. As of September 1, 2004 all 91ܽ personnel (including students and staff) involved in projects using human research subjects who have not completed the 91ܽ workshop, Education in the Protection of Human Research Subjects, are required to complete an online training program before beginning their research. To complete the training titled Protecting Human Research Participants go to http://phrp.nihtraining.com. Once the training module has been completed, you will be prompted to print out a certificate of completion. A copy of this certificate must be submitted with your IRB application or your application will be returned. Please keep a copy of your certificate for your records as it must be attached to all future IRB applications as proof of training compliance. Please send one copy of the completed application to: Inter-Departmental Mail: Patricia Harvey, Sponsored Research, University Center Regular Mail: Patricia Harvey, IRB, LIU, Office of Sponsored Research, 700 Northern Blvd., Greenvale, NY 11548 Exemption Categories Research activities that involve no risk to human subjects and are listed in one or more of the following categories may be reviewed by the IRB through the exempt procedure authorized by 45 CFR 46.101. CHECK THE CATEGORY THAT ACCURATELY DESCRIBES YOUR RESEARCH ACTIVITY:  FORMCHECKBOX  (46.101.b.1) Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as: Research on regular and special education instructions strategies; Research on the effectiveness of or the comparison among existing instructional techniques, curricula, or classroom management methods.  FORMCHECKBOX  (46.101.b.2) Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior UNLESS: The information obtained is recorded in such a manner that human subjects can be identified, either directly (e.g., name) or through identifiers linked to the subject (i.e., through ANY code used with the intent of being traced back to the subject) AND Any disclosure of the human subjects responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects financial standing, employability, or reputation.seq level0 \h \r0 seq level1 \h \r0 seq level2 \h \r0 seq level3 \h \r0 seq level4 \h \r0 seq level5 \h \r0 seq level6 \h \r0 seq level7 \h \r0   FORMCHECKBOX  (46.101.b.3) Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, that is not exempt as described above, IF: The human subjects are elected or candidates for public office OR Federal statute(s) require(s) without exception that the confidentiality of the personally identifiable information will be maintained throughout the research and thereafter (e.g., as in the case with a Certificate of Confidentiality).  FORMCHECKBOX  (46.101.b.4) Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, IF: These sources are publicly available OR The information obtained is recorded in such a manner that human subjects cannot be identified, either directly (e.g., name) or through identifiers linked to the subject (i.e., through ANY code used with the intent of being traced back to the subject)  FORMCHECKBOX  (46.101.b.5) Research and demonstration projects which are conducted by or subject to the approval of the Department of Health and Human Services, and which are designed to study, evaluate or otherwise examine: Programs under the Social Security Act or other public benefit or service programs; Procedures for obtaining benefits or services under those programs; Possible changes in or alternatives to those programs or procedures; Application Endorsements Applications will not be reviewed without the appropriate endorsements. Principal Investigator: I certify that a) the information provided for this project is accurate; b) no other procedures will be used in this project; c) any modifications in this project will be submitted for approval prior to use; and d) study will not be started until final approval had been obtained from the IRB ____________________________________________ _________________ Signature of Investigator Date Conflict of Interest Statement: Could the results of the study provide a potential gain to you, a member of your family, or any of the co-investigators that may give the appearance of a potential conflict of interest? ____NO ____YES, the potential conflicts of interest are described in a cover letter and disclosed on the consent form. Faculty Supervisor (if required): I certify that this project is under my direct supervision and that I am responsible for insuring that the investigator complies with all provisions of approval. ___________________________________________ __________________ Signature of Faculty Sponsor Date Department Chair: My signature below certifies that I have reviewed this research protocol and that I attest to the scientific merit of this study and the competency of the investigator(s) to conduct the project. __________________________________________ __________________ Signature of Department Chair Date     IRB ID#_____________________  PAGE 1 XZg j k     C D    HI鷱顙ymchRh6CJhRh156CJhRhR56CJhRh6CJhRh16CJhRCJaJhRhCJ h<6CJ h<CJh<h3 6CJ h3 6CJh51h3 CJhRh51CJ hRCJh3 5>*CJ h3 CJ h3 5CJh3 h3 5"2YZ U ?  k   D  & F h^dhgd51dh`dh$a$   JKABWX"-t $*$1$ /`p@ P !$1$$ /`p@ P !$1$a$ 1$^gd Z1$gd51gd & F h^gdR & F h^IJK@ABVW-tuvڶڜvng^Pv?P!jh3 CJOJQJUjh3 CJOJQJUh3 5OJQJ h3 5>*h3 OJQJh3 CJOJQJh3 56>*CJOJQJhR56>*CJOJQJh Zh5CJaJhh656CJaJhh:f56CJaJhh-56CJaJhh4r56CJaJhh51h5156CJaJhh5156CJaJhhRh3 6CJtuV6}w}h^h & F ,`p@ P !$*$ /`p@ P !$*$ & F & F ,`p@ P !$*$# /`p@ P !$d*$^ 5TUV^ տ췩~wnddddddjh3 CJUh3 >*OJQJ h3 >*CJh3 5>*CJ h3 5CJ!jth3 CJOJQJUh3 CJOJQJjh3 CJOJQJUh3 OJQJhCJOJQJ h<CJ h^CJ h3 CJ hCJh3 5CJOJQJh3 CJOJQJh3 CJ$OJQJ'  !3489GHIX./mtu_`abpqrt+,45/0￷ۍyslchh3 CJ h3 >*CJ hlCJh3 >*OJQJh3 5CJOJQJ h2sCJh3 5OJQJj\h3 OJQJUjh3 OJQJUh3 OJQJh3 5>*OJQJh3 >*CJOJQJ hCJ h3 5CJjh3 CJU h3 CJjh3 CJU$68.mt`a,4l] `p`'0*h^h% 2@ P !$`'0*`*$^``  h^h & F /@ P !$`'0**$ 2@ P !$`'0**$% 2p~ P !$`'0*@ `*$^@ `` 4012346qqqqoj$a$! & F 2$ @ P !$`'0**$ ^`' 5h@ P !$`'0**$^` ,`p@ P !$*$gd & F ,`p@ P !$*$ 03467EFGIV]uv+KLM'(f ,!!!!p"q"""""""# #λΰ||wokkkkhRhRCJaJ h~5hCJaJhRh3 CJaJ h3 5h3 h3 OJQJ h3 CJh3 CJOJQJh3 5CJOJQJ$jh3 5CJOJQJUh3 5CJOJQJjh3 5CJOJQJUh3 5OJQJ hCJ h>*CJ*\]u(4 e f +!,!s!!!!q"" # # ####p^p$a$ # # # ########4#5#6#<#=#>#?#A#B#C#νh-0JmHnHu h0Jjh0JUh hCJhDjhDU hR5>*hRh3 CJaJ#####4#5#@#A#B#C#$a$$a$ ,&P/ =!"#$% tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH <`< NormalCJ_HmH sH tH @  Heading 4E$ /`p@ P !$*$@&^5>*CJOJQJ@  Heading 5H$ 2@ P !$`'0**$@&^5>*CJOJQJDA`D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4@4 Header  !4 @4 Footer  !L.@L  TOA Heading*$1$ $ CJOJQJVC@"V Body Text Indentdx^ CJOJQJS@2 Body Text Indent 3D ,`0@ P !$`*$^`` CJOJQJR@B Body Text Indent 2M 5h@ P !$`'0*p*$^p`5CJOJQJ.)@Q. 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