Kansas Department of Health and Environment
Institutional Review Board
REQUEST FOR EXEMPTION
Name of investigator:
Phone number and email:
Name of protocol
No researcher should determine that a planned data collection or research intervention is exempt from
IRB oversight.All protocols should be referred to the chair of the KDHE IRB (or designee) to
determine whether exemption from KDHE IRB oversight is legitimate.
Does this protocol have a current approval from another IRB?
If yes, please provide the IRB name and protocol number for this specific project and attach
documentation of project approval.
If you are requesting exemption, on what basis is an exemption being sought?
Please attach a brief description of the proposed project.
Do Not Write Below Line; For IRB Use Only
Decision of reviewer: Exemption Granted
Signature ____________________________ Date____________________________