Cazenovia College Institutional Review Board
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1 Cazenovia College Institutional Review Board Full Proposal Form This proposal is: original submission modification of previous submission renewal Project Title: Principle Investigator: Contact Contact Phone: Co-Investigator(s): Study Time Frame: External funding: Yes No Source: Internal funding: Yes Source: No Protected Populations: (check any that apply) Minors Pregnant Women Prisoners Mentally Handicapped or Disabled Other Protected Populations By signing below, I, the Principle Investigator assure that I have read the statement of Cazenovia College ethics, including the responsibility to obtain Informed Consent from participants and will comply. Signature: Date: This form must be completed in full and submitted to the IRB Chair. Hard copy forms can be submitted to Ezra Wegbreit, Ph.D., 22 Sullivan St., Cazenovia College, Cazenovia, NY (or campus mail); digital forms can be ed to ewegbreit@cazenovia. Institutional Review Board Cazenovia College (phone) ewegbreit@cazenovia.edu Page 1
2 Research Abstract Please make responses as clear and concise as possible. If additional space is needed for your responses, use the space provided on the last page. Please indicate the section number and letter for which you are providing additional information. I. Participants A. Who will your participants be and how will you recruit them? B. Will anyone be excluded from this study by basis of age, gender, race, or ethnic group? C. Approximately how many participants will you recruit for this study? D. If human subjects are minors or another vulnerable population or legally restricted group, what is your justification for using this group? What precautions have to taken to make sure your treatment of this group is within the ethical guidelines put forth by the IRB? II.Procedures A. What type of information will you collect from participants ow will you collect and record this information? B. Who will interact with the participants? Institutional Review Board Cazenovia College (phone) Page 2
3 C. Where will participation in this research occur? Are there any risks to using this location? D. Approximately how much time will total participation in this study take for each participant? If multiple testing sessions are being used, how long for each testing session? E. Will participants be paid or compensated in any way for their participation in your study? Will payment have any impact on confidentiality or anonymity of your study? If extra credit will be offered as compensation, will alternative forms of extra credit be provided to students who do not wish to participate? If so, what will this alternative form of compensation be? III. Risk A. Are their any immediate risks to participants (this includes physical, psychological, social, legal, economic, or another risks you can foresee)? B. Are there any long term or delayed risks to participants? C. What is your rationale for these risks? Make sure to include why options for running this study without risk are not possible or feasible and what benefits will be gained from conducting this research that justify the risks. Institutional Review Board Cazenovia College (phone) Page 3
4 Deception IV. A. Describe any deception you plan to use in this study and provide justification for its use. B. Provide a detailed written description of the debriefing process, which includes a complete explanation of the study and any deception used. C. How will you keep a permanent record of debriefing each participant? V. Safeguarding Participants Identity A. How will you use the information gained from the participants? Who will have access to this information, including access in publications? Will this access be in the form of aggregate data or individual data? B. ill you safeguard the information from participants in both the short-term and the long-term? How will the information be kept confidential? C. Will participants be able to be identified directly or through identifiers? Institutional Review Board Cazenovia College (phone) ewegbreit@cazenovia.edu Page 4
5 Attachments Please indicated which of the following attachments are included with your proposal submission: Consent Form Survey/Interview Debriefing Other Additional Information Please use the space below for any additional information you were not able to fit in the abstract. Institutional Review Board Cazenovia College (phone) Page 5
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