ࡱ> !` tbjbj\\ 0>>'%%DDDDDDDX8<XI2"_S|HHHHHHH$"KhMlHDHDDIZ$Z$Z$dDDHZ$HZ$Z$?ElDDG tU2 F*H$I0IF&M "MTGMDGL6Z$Q,}/HH$XIXXXXXXXXXDDDDDD For Office Use Only: Date Reviewed:_____________ IRB Case No:___________________ Action:  FORMCHECKBOX Approved  FORMCHECKBOX Exempt  FORMCHECKBOX Expedited  FORMCHECKBOX Full IRB Reviewer:___________________  FORMCHECKBOX Not Approved BLUE MOUNTAIN COMMUNITY COLLEGE APPLICATION FOR THE CONDUCT OF RESEARCH INVOLVING HUMAN SUBJECTS INSTITUTIONAL REVIEW BOARD (IRB) The Blue Mountain Community College IRB reviews all requests to conduct research involving human subjects. It is the Investigator's responsibility to give complete information regarding procedures and the informed consent process. If the principal investigator is a student, the application must be approved and signed by the applicant's faculty sponsor and the department chair. After completing the application and obtaining required signatures, one original of the application and all supporting materials must be forwarded to the BMCC IRB, Institutional Advancement Office, Pendleton Campus. The IRB will notify each applicant of the IRB's decision. If you have questions, please contact the IRB at (541) 278-5891. The Principal Investigator must supply the required documentation listed below:  FORMCHECKBOX  A copy of all questionnaires or survey instruments  FORMCHECKBOX  Informed consent document(s) or minor assent document(s)  FORMCHECKBOX  Letters of approval from cooperating institutions (if appropriate)  FORMCHECKBOX  All required signatures Please type or print responses. PROJECT TITLE: FORMTEXT       Principal Investigator's Name  FORMTEXT       (If more than one principal investigator, provide supplementary page with contact information.) Department FORMTEXT       Phone  FORMTEXT       Mailing Address  FORMTEXT       Email  FORMTEXT      ______________ Faculty Sponsor  FORMTEXT       Phone  FORMTEXT       Department  FORMTEXT       Is this a class project? yes  FORMCHECKBOX  no  FORMCHECKBOX  Thesis? yes  FORMCHECKBOX  no  FORMCHECKBOX  Other  FORMTEXT       2. Project Start Date:  FORMTEXT       Project End Date:  FORMTEXT       3. Is a proposal for external support being submitted? yes  FORMCHECKBOX  no  FORMCHECKBOX  Agency or Sponsor:  FORMTEXT       Deadline:  FORMTEXT       If yes, you must submit one complete copy of the proposal with this application. a. Is this a continuation of an IRB project? yes  FORMCHECKBOX  no  FORMCHECKBOX  If yes, previous IRB case number:  FORMTEXT       4. PROJECT DESCRIPTION: The IRB must have sufficient information about what will happen to the subjects in order to evaluate and estimate possible risks. Assurance from the investigator, no matter how strong, will not substitute for a description of the transactions between the investigator and subject. Provide a brief, non-technical summary of the proposed research.  FORMTEXT       SUBJECT SELECTION: Will subjects be less than 18 years of age? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Age range of subjects From  FORMTEXT       To FORMTEXT       Will subjects be students at BMCC? Yes  FORMCHECKBOX  No  FORMCHECKBOX  How many subjects will participate?  FORMTEXT       How will subjects be selected, enlisted or recruited?  FORMTEXT       INFORMED CONSENT PROCESS: Describe the informed consent process and attach a copy of all consent and/or assent documents.  FORMTEXT       PROCEDURES: Provide a step-by-step description of each procedure, including the frequency, duration, and location of each procedure.  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":"v"Ȼﭤqhh`QBh/7hCJOJQJaJh/7h$&CJOJQJaJh$&OJQJh5OJQJh5OJQJmHnHu%jh$&5OJQJUmHnHu jh$&5OJQJUh$&5OJQJjh$&5OJQJUh~?d6CJOJQJaJh*X6CJOJQJaJhxI6CJOJQJaJh;6CJOJQJaJhh$&6CJOJQJaJv"""""""""""""###0#:#B#F#P#R#f#h#j#t#v#|#~###⠕xdNx+jh/7h$&>*OJQJUmHnHu&jh/7h$&>*OJQJUh/7h$&>*OJQJ jh/7h$&>*OJQJUh/7hOJQJh/7h$&CJOJQJaJ#jh/7h$&OJQJU#jh/7h$&OJQJUjh/7h$&OJQJUh/7h$&OJQJh~?dOJQJh/7h{OJQJ############$$$2$4$P$R$T$V$X$$$$$ۺsaRFh/7h$&>*OJQJh~?dh$&CJOJQJaJ#j^h/7h~?dOJQJU#jh/7h~?dOJQJUjh/7h~?dOJQJUh/7h~?dOJQJh~?dCJOJQJaJh/7h$&CJOJQJaJh/7h$&OJQJ+jh/7h$&>*OJQJUmHnHu jh/7h$&>*OJQJU&jrh/7h$&>*OJQJU#V$X$$$^%`%b%V&b'.((* *+,, -XXXY & F gd & F gdgd & Fgd*Xh^hgd  !gd~?d P !gd~?d$$$$$$2%4%6%8%L%N%P%Z%\%^%b%%%%ۺzkYzQE*OJQJUmHnHu jh/7h$&>*OJQJU&jh/7h$&>*OJQJU%%%R&T&V&X&l&n&p&x&**** ** *$*+++0+2+4+<+øÑxpd[SSøAÑ#j6hhOJQJUh$&OJQJh$&5OJQJh/7h$&5OJQJhOJQJh5OJQJhhOJQJmHnHu(jhhOJQJUmHnHu#jhhOJQJUhhOJQJjhhOJQJUhh6CJOJQJaJh*X6CJOJQJaJhh$&6CJOJQJaJ  CONFIDENTIALITY AND ANONYMITY: How will subjects' privacy be maintained and confidentiality be guaranteed?  FORMTEXT       RISKS: Describe all known and anticipated risks to the subject including side effects, risks of placebo, risks of normal treatment delay, etc.  FORMTEXT       BENEFITS: Describe the anticipated benefits.  FORMTEXT       RESPONSIBILITIES OF THE PRINCIPAL INVESTIGATOR: Any additions or changes in procedures in the protocol will be submitted to the IRB for written approval prior to these changes being put into practice. Any problems connected with the use of human subjects once the project has begun, must be brought to the attention of the IRB. The principal investigator and his or her designee are responsible for retaining Informed Consent Documents for a period of three years after the completion of the project. The principal investigator may not initiate any research involving human subjects until written notification of IRB approval or compliance with any and all contingencies made in connection with said approval has been received. Failure to provide all required information will result in return of your IRB application for correction prior to IRB review. SIGNATURES: I certify to the best of my knowledge the information presented is an accurate reflection of the proposed research project and that I intend to comply with the letter and spirit of the BMCC Policy on the Protection of Human Subjects in Research. A. Principal Investigator Date Approval by faculty sponsor (required for all students): I confirm the accuracy of this application, and I accept responsibility for the conduct of this research, the supervision of human subjects, and maintenance of informed consent documentation as required by the IRB. Faculty Sponsor Date Approval by Department Chair (required for all students): I confirm the accuracy of the information stated in this application. I am familiar with, and approve of the procedures that involve human subjects. 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