Docstoc

newark public schools

Document Sample
newark public schools Powered By Docstoc
					Revised 10/08


                     NEWARK PUBLIC SCHOOLS
   NEWARK PUBLIC SCHOOLS RESEARCH AND EVALUATION REVIEW PANEL

                   INSTITUTIONAL REVIEW BOARD (IRB) APPLICATION

Submit form completed, including any required attachments, for each project involving human subjects. The
IRB meets every other month to evaluate proposals, and approval is usually granted for one year. See IRB
Guidelines and Procedures for details. Please submit package at least 45 days prior to next scheduled IRB
review meeting of the NPS Research and Evaluation Review Panel

Project Title: ___________________________________________________________________

Project Description: ___________________________________________________________________
(in non-technical language)_____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Study is: (a) Doctoral Dissertation:______; (b) Master’s Thesis_______; (c) Other (Specify)_____________

(If research is for graduate studies, please also complete the Graduate Student Research Approval Status form.)


Project Director: _________________________ Dept.: ____________________ Phone: ____________

E-mail Address: _________________________________________


Signature: _________________________________________________ Date: ______________________
(My signature confirms that I have read the completed IRB Application, and agree that it accurately represents the
planned research.)


Principal Researcher: ____________________ Affiliation: _________________ Phone: ____________

E-mail Address: ________________________________________

Home Mailing Address: __________________________________________________


Signature: _________________________________________________ Date: ______________________
(My signature confirms that I have read and completed the IRB Application. I agree that it accurately represents the
planned research, and that I will supervise this research project.)


Project Information
1. Human Subjects. (Describe briefly (include age/gender): _____________________________________________
_____________________________________________________________________________________

          Are any of the following included? Check all that apply.
                  _____ Minors (under age 18) ? If YES, specify age range(s):

                  ________________________________________________________________________________________

                                                                                                                       1
Revised 10/08

                     _____ Members of physically, psychologically or socially vulnerable population? Explain Briefly:

                     __________________________________________________________________

2. How are subjects selected/recruited/sampled? Explain Briefly: ________________________




3. How many subjects will be included in the study? Explain Briefly

________________________________________________________________________________


4. Identification of subjects.

          ___ Anonymous, no identification             ___ Identified by name and/or address or other          ___ Confidentiality Plan



5. Subject matter or kind(s) of information to be compiled from/about subjects.

   Describe briefly:_______________________________________________________________________
                     _______________________________________________________________________

          Is information on any of the following included? Check all that apply.

          ___ Sexual behavior           ___ Illegal or anti-social conduct      ___ Family income
          ___ Alcohol use/abuse         ___ Drug use/abuse                      ___ Political or religious affiliations or beliefs
          ___ legally recognized privileged relationships, such as those of lawyers, physicians or ministers;


6. Means of obtaining the information. Check all that apply.
          ___ Mail survey (Attach questionnaire/instrument)                 ___ On-site survey (Attach questionnaire/instrument)
          ___ Examine public documents, records, data, etc.                 ___ Examine private documents, records, data, etc.
          ___ In-person interviews/survey (Attach questionnaire/instrument) ___ In-person interviews/survey (Attach questionnaire/instrument)
          ___ Use of standard educational tests, etc.
          ___ Other means (specify): __________________________________________________________________________________

          Will subjects be videotaped, audio-taped or photographed? __________________________________________________________



7. Estimated time required for research activities by participating students and staff: _________

___________________________________________________________________________________



8. Is the NPS Parental/Guardian and Student Participation Consent Form being used?

                                                                                                                ___Yes               ___No


9. Will subject(s) receive an explanation of the research before and/or after the project?

                                                                                                                 ___Yes                ___No



                                                                                                                                                2
Revised 10/08



   NEWARK PUBLIC SCHOOLS RESEARCH AND EVALUATION REVIEW PANEL

                          Signature and Acknowledgement Page




I, _______________________________, (print name) as the Principal Researcher,

hereby state that I have reviewed the Newark Public Schools Research and Evaluation

Panel’s Guidelines and Procedures , have completed the Research Summary, and

have completed and signed the IRB Application. By signing in the delineated space

below, I acknowledge that I fully understand the terms and conditions set forth in all of

the aforementioned documents. I further acknowledge that if my Research Project is

approved by the Newark Public Schools Research and Evaluation Review Panel,

whether by expedited or full approval, the Newark Public Schools, should it determine

that any of the terms and conditions have been breached, reserves the right to

immediately revoke its approval to conduct the research. I further acknowledge that I,

along with the institution I represent, may be subject to liability for any damages

resulting from the breach of any terms and conditions of the aforementioned

documents.


Dated: ________________________



Signature:______________________________
                 Principal Researcher




                                                                                            3
Revised 10/08



   NEWARK PUBLIC SCHOOLS RESEARCH AND EVALUATION REVIEW PANEL

                          Signature and Acknowledgement Page




I, ______________________________________, (print name) as the Project Director,

hereby state that I have reviewed the Newark Public Schools Research and Evaluation

Panel’s Guidelines and Procedures , the completed Research Summary, and have

signed the IRB Application. By signing in the delineated space below, I acknowledge

that I fully understand the terms and conditions set forth in all of the aforementioned

documents. I further acknowledge that if my Research Project is approved by the

Newark Public Schools Research and Evaluation Review Panel, whether by expedited

or full approval, the Newark Public Schools, should it determine that any of the terms

and conditions have been breached, reserves the right to immediately revoke its

approval to conduct the research. I further acknowledge that I, along with the institution

I represent, may be subject to liability for any damages resulting from the breach of any

terms and conditions of the aforementioned documents.



Dated: ________________________


Signature: ______________________________
                Project Director




                                                                                            4

				
DOCUMENT INFO