ࡱ> W bjbjff 3ii$%#  8G4{\Ev2 !"+!+!+!"&&*(^D`D`D`D`D`D`D$EHJD.)^""".).)D+!+!3E+++.)R8+!+!^D+.)^D++>(*+!<P)&A:JDE0E`AKz*Kt*BK*B .).)+.).).).).)DD+.).).)E.).).).)K.).).).).).).).).) Y q: Section A Institutional Review Board Committee (IRB) Submission Checklist YOU MUST SUBMIT HYPERLINK "/academics/graduate-studies/institutional-review-board/proposal-submissions/submit-your-irb-proposal/"ELECRONICALLY OR TO HYPERLINK "mailto:IRB@BEMIDJISTATE.EDU"IRB@BEMIDJISTATE.EDU AS A SCANNED .PDF (ELECTRONIC SUBMISSION PREFFERED) Project title:  FORMTEXT       Principal Investigator(s):  FORMTEXT       The IRB will NOT review proposals that do not include: Applicable/Not-Applicable* 1. Completed IRB Human Research Approval Form and Ethical  FORMCHECKBOX   FORMDROPDOWN  Compliance Questionnaire (See Section A) and attach it to the documents being submitted for review. 2. A 100-150 word abstract or summary of the proposed study.  FORMCHECKBOX   FORMDROPDOWN  3. A complete statement of the research methods, including copies of the instrument(s) being used to collect data. (Do not include  FORMCHECKBOX   FORMDROPDOWN  literature review chapters or proposals.) 4. Informed Consent Form(s) See Section B for further  FORMCHECKBOX   FORMDROPDOWN  description and sample consent form. 5. Signed letter of permission from institution if research to be  FORMCHECKBOX   FORMDROPDOWN  conducted is in an institution such as school, hospital, etc. 6. Debriefing Statement See Section C for further information  FORMCHECKBOX   FORMDROPDOWN  and sample (minimal risk proposals need to include this form). 7. a) The original and one (1) copy of this information are required  FORMCHECKBOX   FORMDROPDOWN  for an Expedited Review. OR b) The original and six (6) copies of this information are required  FORMCHECKBOX   FORMDROPDOWN  for a Full Review 8. CITI Collaborative Institutional Training Initiative Certificate of Completion  FORMCHECKBOX   FORMDROPDOWN  [All investigator(s) and faculty/sponsor are required to complete] *Please indicate those items not applicable. Thank you. APPROVAL FORM AND ALL ATTACHMENTS MUST BE TYPED! 91̽/Northwest Technical College Institutional Research Board Human Research Approval Form Title of Study:  FORMTEXT       Date Submitted:  FORMTEXT       Project starting date:  FORMTEXT       Project ending date:  FORMTEXT       Principal Investigator(s):  FORMTEXT       BSU Student ID#, if applicable:  FORMTEXT       Please indicate if you are: BSU/NTC Faculty  FORMTEXT       BSU/NTC Student(s)  FORMTEXT       Non-BSU/NTC  FORMTEXT       Have all Principal Investigators listed completed the training for Human Subjects research?  FORMTEXT       Yes  FORMTEXT       No Street Address:  FORMTEXT       Telephone:  FORMTEXT       City, State, & Zip  FORMTEXT       E-mail Address:  FORMTEXT       Co-Investigators:  FORMTEXT       Faculty Advisor/Sponsor:  FORMTEXT       Request:  FORMCHECKBOX  HYPERLINK "https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/common-rule-subpart-a-46104/index.html"Exempt (include reasons below):  FORMCHECKBOX  HYPERLINK "https://www.hhs.gov/ohrp/regulations-and-policy/guidance/categories-of-research-expedited-review-procedure-1998/index.html"Expedited Review (include reasons below):  FORMCHECKBOX  Full Review: Is the submitted document in draft form yet to be pre-tested?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (If Yes, a final copy of the survey instrument must be re-submitted upon completion.) Can the title of this study be made public before the completion date?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you using BSU and/or NTC students for this study?  FORMCHECKBOX  Yes  FORMCHECKBOX  No The students faculty advisor must first approve all student research. Signature denotes the advisors approval of the project and must be obtained prior to forwarding to the HSC in the School of Graduate Studies. ______________________________________________ ___________________ Signature of Advisor/Sponsor Date Has the Advisor/Sponsor completed the training for Human Subjects research? ___ Yes ___ No ---------------------------------------------------------------------------------------------------------------------HUMAN SUBJECTS COMMITTEE RECOMMENDATION: _______ Exempt Review _______ Approved _______ Revise and resubmit _____ Not approved _______ Expedited Review _______ Approved _______ Revise and resubmit _____ Not approved _______ Full Review _______ Approved _______ Revise and resubmit _____ Not approved ____________________________________________________ ________________________ IRB Reviewers Signature Date Ethical Compliance Questionnaire Complete all items on this form and/or on separate sheets of paper attached to this form. Subject Recruitment and Requirements (includes subjects recruited for pre-testing). What type of human subjects will you require? (gender, age, location, affiliation, special characteristics)  FORMTEXT       Where and how do you propose to recruit participants/subjects?  FORMTEXT       If your study involves subjects in institutions (schools, hospitals, other agencies), how will institutional consent be obtained? A single letter of permission from an institutional representative is required. Attach original copy to the proposal. See Sample Permission Letter. Not required if you are using 91̽ and/or Northwest Technical College human subjects. However, notification of the survey will be provided to the VP for Student Development & Enrollment after IRB approval is secured. 4a. Will your study use minors (subjects under 18 years of age)?  FORMCHECKBOX  Yes If Yes proceed to 4b.  FORMCHECKBOX  No If No, explain how you will ensure that minors will NOT complete your study. i.e. The first question in your survey should ask participants to identify their age. If under the age of 18 years, they should be instructed NOT to complete the survey.  FORMTEXT       Proceed to 5a. 4b. How will consent be obtained if subjects are minors and/or incapable of giving legal consent?  FORMTEXT       4c. Is informed consent form attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT       5a. If subjects are of legal age, how will consent be obtained?  FORMTEXT       5b. Is informed consent form attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT       How much time will be required of each participant?  FORMTEXT       7a. Will subjects be compensated for participation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT       7b. If yes, please specify:  FORMTEXT       8a. Is confidentiality assured?  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" """"""""""""""""""#$2$X$u$v$w$$$˾˪ؾqdh$5CJOJQJaJh$h .5CJOJQJaJh$h(G CJOJQJaJh$h(G CJOJQJh$hIPCJOJQJ'jIh$hKZvCJOJQJUh$h\CJOJQJh$hBCJOJQJ!jh$hBCJOJQJU,jh$hBCJOJQJUmHnHu $$$c%d%e%%%%%%%%%%%%%%%%%%%&'''ϿvvbvvvQ!jh$hZCJOJQJU'j5h$hZCJOJQJUhZCJOJQJ'jh$h+uCJOJQJUh$hiCJOJQJ!jh$hiCJOJQJUh$h\CJOJQJh$hB5CJOJQJaJh$h]"5CJOJQJaJh$h .5CJOJQJaJh$h+?5CJOJQJaJ''( (((*(()))))r*t**N+P+x+z+++,gd$ & Fgd7 0^`0gdB 0^`0gdB^ 0^`0gdZ ^`gdZ''''''((((( (&(((*((())) ) )))))))f)ηέxdMMMMMx,jh$hBCJOJQJUmHnHu'j!h$hKZvCJOJQJUh$hBCJOJQJ!jh$hBCJOJQJUh$h\CJOJQJh\CJOJQJhZCJOJQJ,jh$hZCJOJQJUmHnHu!jh$hZCJOJQJU'jh$hZCJOJQJUh$hZCJOJQJf)h)))))))))))))))))))))))))))*r*t*v*x**zccccc,jh$hBCJOJQJUmHnHu'j h$hKZvCJOJQJU!jh$hBCJOJQJUh$hBCJOJQJ'j h$hY CJOJQJUh$h\CJOJQJ'jh$hY CJOJQJUh$hiCJOJQJ!jh$hiCJOJQJU!*************+++++"+$+@+B+D+F+N+P+R+f+h+j+l+ڶpcO'j["h$hKZvCJOJQJUh$hBCJOJQJ'j!h$hY CJOJQJU'jo!h$hY CJOJQJU!jh$hiCJOJQJUh$hiCJOJQJh$h\CJOJQJ,jh$hBCJOJQJUmHnHu!jh$hBCJOJQJU'j h$hKZvCJOJQJUl+n+p+r+t+v+x+z++++++++,,,,, , ,,,v,z,|,,,,,,,,,˾˪؝k'jG#h$hY CJOJQJU!jh$hiCJOJQJUh$hiCJOJQJh$h]"CJOJQJ'j"h$hKZvCJOJQJUh$h\CJOJQJh$hBCJOJQJ!jh$hBCJOJQJU,jh$hBCJOJQJUmHnHu",,,,-->-@-h-j- | |4|6|}}"~$~L~N~v~x~~~,. & Fgd$^,,,,,,,,,,,,,,,--->-@-B-V-X-Z-\-^-`-b-d-f-h-j-n--wwwwwjVwwwww'j$h$hKZvCJOJQJUh$h55CJOJQJ,jh$hBCJOJQJUmHnHu'j3$h$hKZvCJOJQJUh$hBCJOJQJ!jh$hBCJOJQJUh$h\CJOJQJh$hiCJOJQJ!jh$hiCJOJQJU'j#h$hY CJOJQJU!------------.|| | ||"|$|&|(|*|,|.|0|2|4|6|V|X|xaaaaaWh<CJOJQJ,jh$hBCJOJQJUmHnHu'j &h$hKZvCJOJQJUh$hBCJOJQJ!jh$hBCJOJQJUU'j%h$hY CJOJQJUh$h\CJOJQJ'j%h$hY CJOJQJUh$hiCJOJQJ!jh$hiCJOJQJU No  FORMTEXT       8b. If Yes, how? (i.e. Signed Informed Consent forms and raw data will be stored separately in a locked cabinet in the Faculty/Sponsor s office; no names or other identifying items will be connected to the study instrument.  FORMTEXT       8c. If no, why not?  FORMTEXT       9. What benefits do subjects obtain by participating?  FORMTEXT       Subject Risk Certain practices are generally to be avoided. If any are included in the proposed study, check the blank next to the appropriate category and justify with attachments.  FORMCHECKBOX  Deception  FORMCHECKBOX  Pain, threat, or aversive stimulation  FORMCHECKBOX  Embarrassment  FORMCHECKBOX  Invasion of privacy  FORMTEXT       III. Debriefing When and how will subjects be provided with feedback about the study?  FORMTEXT       2a. Is a debriefing form attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Include debriefing statement when applicable; minimal risk proposals must include this form)  FORMTEXT       2b. If deception has been used, how will the subject be informed?  FORMTEXT       What follow-up supports will be available if subjects experience undesirable consequences of participation? (ONLY BX|}}}}~~~~~~~~~ ~"~$~L~N~P~d~f~h~j~l~n~p~r~t~v~x~~~~~~  ȴ՝ȉ՝u՝'jm'h$hKZvCJOJQJU'j&h$hKZvCJOJQJU,jh$hBCJOJQJUmHnHu'j&h$hKZvCJOJQJUh$hBCJOJQJ!jh$hBCJOJQJUh$h\CJOJQJh$h+?CJOJQJ-,.Āƀ8:<>Z\^dҁԁցʶʢʎzi!jh$hBCJOJQJU'jE)h$hY CJOJQJU'j(h$hY CJOJQJU'jY(h$hY CJOJQJU'j'h$hKZvCJOJQJUh$hiCJOJQJ!jh$hiCJOJQJUh$h\CJOJQJh$h\OJQJ$.8:ҁԁ ؂ڂ>@hj`gd$gd$^gd$ & F & Fgd6rW^ց ƂȂʂ̂΂Ђ҂Ԃւ؂ڂ&(Dη󰰩ηΜ{j{!jh$hiCJOJQJUh$hiCJOJQJ'j1*h$hKZvCJOJQJUh$h\CJOJQJ h$h\ h$h6rW,jh$hBCJOJQJUmHnHu!jh$hBCJOJQJU'j)h$hKZvCJOJQJUh$hBCJOJQJ"DFHJVXtvxz܃:>@BVXZ\^`bdfhͬwcLLLLL,jh$hBCJOJQJUmHnHu'j+h$hKZvCJOJQJUh$hBCJOJQJ!jh$hBCJOJQJUh$h+?CJOJQJh$CJOJQJ'j+h$hY CJOJQJUh$h\CJOJQJh$hiCJOJQJ!jh$hiCJOJQJU'j*h$hY CJOJQJUhj   468:<>@BDFH\^˾˓󉉇˾s˓˾l h$h\'j,h$hKZvCJOJQJUUh$&CJOJQJ,jh$hBCJOJQJUmHnHu'j ,h$hKZvCJOJQJUh$hBCJOJQJ!jh$hBCJOJQJUh$CJOJQJh$h\CJOJQJh$hE4CJOJQJ*SU students may be referred to the BSU Counseling Center; all others (including NTC students) must be referred to an agency outside of BSU).  FORMTEXT       Materials What questionnaires, inventories, tests, or other instruments will be used? Attach copies unless the instrument is universally familiar.  FORMTEXT       2. What electrical, electronic, or mechanical equipment will be used? If any have been specially constructed or modified for use in this study, provide a description with sufficient detail so that any physical danger may be assessed. Supplementary documents may be attached if necessary.  FORMTEXT       FEDERAL GUIDELINES REQUIRE ALL RECORDS AND DATA BE KEPT FOR THREE YEARS. Completed proposals should be submitted to theFH\^prDFjnptvz|$a$gd<$a$gdT8$a$gd6rW 0^`0 & F & Fgd6rWprtv $ժժ||z|t|t hc"CJU h<CJh$hUCJh$h\OJQJ'jk-h$hKZvCJOJQJU,jh$hBCJOJQJUmHnHu'j,h$hKZvCJOJQJU!jh$hBCJOJQJUh$hBCJOJQJh$h\CJOJQJ* IRB Committee at HYPERLINK "mailto:IRB@BemidjiState.edu"IRB@BemidjiState.edu. Once submitted, please allow ten (10) business days for review and/or approval. 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