ࡱ> MOLa +bjbj *NxEbxEb#vvvvv<T!VK$oX!Z!Z!Z!Z!Z!Z!$a#&~!vxxx~!vv!xvvX!xX!4 Ei D!!0! 'L'( 'v X>A,m$~!~!\L!xxxx'B <: NICHOLLS STATE UNIVERSITY Request for HSIRB Exemption Name(s) of Principal Investigator(s): _____________________________ Phone: ______________ Other Investigators: ________________________________________________________________ Faculty Sponsor (If Student Research): _____________________________ Phone: _____________ 2. College: ___________ Department: ________________________ Phone: _____________ Title of Project or Proposal:_________________________________________________________ 4. Description of Project or Proposal (attach additional information as needed): Briefly describe the population of human subjects involved (e.g., University students, community members, athletes, homemakers, school children, etc.) You MUST indicate if this participation is VOLUNTARY or NOT. Subjects must be 18 or older for HSIRB Exemption. Briefly describe your research procedures and techniques of data collection (e.g., interview, questionnaire, test administration, observation of public behavior, etc.). You MUST include a printed copy of any data collection instrument(s) as well as active link(s) if online or electronic data collection methods are being utilized. c. Briefly describe the objectives of your research (e.g., what hypotheses you are testing.) 5. a. How will you recruit subjects? YOU MUST submit VERBATIM COPIES of all letters, emails, notices, advertisements, etc. and/or all oral presentations to be used to recruit subjects/ participation in the research project (e.g. scripts of direct person-to-person solicitation, telephone solicitation, newspaper solicitation, letters of solicitation, email solicitation, notices of solicitation posted to Facebook or Moodle, etc.). b. List all criteria for including subjects. c. List all criteria for excluding subjects. 6. Describe subject benefits and costs: a. Indicate what, if any, benefits may accrue to each of the following: (Payment to research subjects for participation in studies is considered a benefit.) 1) The human subjects involved: 2) Individuals who are not subjects, but who may have similar problems: 3) Society in general: b. State type, amount, method of disbursement, schedule of payment to be offered, and the effect of withdrawal from participation in the study, if any: c. Estimated costs to each subject due only to the research participation: 1) Time (i.e., total time commitment for the duration of the project) 2) Money 3) Is repeated testing required? Explain: 7. BASIS OF REQUEST FOR EXEMPTION - One of the following (A-E) must be checked. _____ A. The research will be conducted only in established or commonly accepted educational settings (like classrooms) AND it involves normal educational practices such as research on regular and special educational instructional strategies, or research on the effectiveness of, or the comparison among, instructional techniques, curricula or classroom management methods. _____ B. It will be conducted using only questionnaire or interview survey methods AND the subjects are elected or appointed public officials or candidates for public office. _____ C. It is limited to the collection and study of existing data, documents, records, pathological or diagnostic specimens which are available to the public. (Request options for exemption continued on next page) _____ D. It is limited to the collection and study of data obtained using only the following techniques AND the data or information obtained will be recorded in such a manner that subjects cannot be identified, directly or indirectly, through identifiers linked with the subjects: Check the applicable technique(s): _____ 1. The data will be obtained through the use of educational tests (cognitive, diagnostic, aptitude, achievement, etc.), or _____ 2. Data will be obtained by observing the public behavior of subjects, or _____ 3. Data will be obtained using survey or interview procedures, or _____ 4.Data will be obtained from existing documents, records, pathological or diagnostic specimens. _____ E. It is limited to the collection and study of data obtained by: 1. Observing the public behavior of the participants, or 2. Using survey or interview procedures, AND: BOTH OF THE FOLLOWING MUST BE CHECKED IF E-2 IS THE BASIS FOR THE REQUESTED EXEMPTION: _____ i) The information collected about the subjects behavior does not involve sensitive subjects such as illegal or immoral conduct, drug or alcohol use, sexual behavior, mental illness, or other possibly personally embarrassing subjects AND, _____ ii) The information collected about subjects, if it became known to outsiders, could not reasonably be expected to place the subject at risk of civil or criminal liability, or be damaging to the subjects social or financial standing or employability. 8. Attach copies of current CITI Training certificate(s) for all investigators. Faculty Sponsors of student research must provide a copy of their current CITI Training certificate. Please be sure to select (enroll) and complete the appropriate series of modules based on your area / learner group. URL TO CITI TRAINING: https://about.citiprogram.org/en/homepage/ There are 5 different learner groups for Ӱɴý: Faculty Researchers / Faculty Sponsors If you are conducting research involving human subjects or if you are the faculty sponsor / supervisor of student research which does NOT involve the areas of biomedical research. NOTE: Nursing and Allied Health Faculty are required to complete the HIPAA module (not suggested as for all other faculty). Student Researchers (Not Nursing/Allied Health): Any research being conducted by a student or student group (either thesis, class project, service/experiential learning, or academic oriented research) where human subjects are involved (surveyed, experimental design, and/or observation). IRB Members: Any member of the HSIRB Committee at Ӱɴý Nursing and Allied Health Students: Modules in this group include the Basic Social-Behavioral- Educational Modules as well as additional required modules, as required by consensus of the Faculty within the respective College and Department. Biomedical Data or Specimens/Researchers (Faculty and Students): Any Faculty / Students whose Research involves the use or collection of biomedical data and/or specimens. NOTE: Depending on the exact protocols used. If additional data is collected by means of a survey from subjects, then the researchers (both faculty, faculty sponsors and students) are required to complete additional modules (Faculty Faculty Researchers/Research Sponsors; Students Student Researchers (Not Nursing or Allied Health). 9. STATEMENT OF RISK: The undersigned certify that they believe that the conduct of the above described research creates no risk of physical or emotional harm, or social or legal embarrassment to any participating human subject. _____________________________________ Signature of Principal Investigator Date 10. FACULTY SPONSOR (if a student is the principal investigator) ______________________________________ Signature of Faculty Sponsor Date 11. RECOMMENDATION OF HSIRB REPRESENTATIVE OR HSIRB CHAIR: I recommend that the above described research project be exempt from review. _______________________________ HSIRB PROTOCOL NUMBER ______________ Signature of Chairperson Date (Assigned by HSIRB) NOTE APPROVE HSIRB Research is valid for a 12 month period of time from the date approved. Approved research can be renewed and extended for a 1 year period at the request of the principle investigator / faculty member PRIOR to the expiration of an existing HSIRB Protocol Number. Projects can be renewed a maximum of two (2) times. Any faculty wishing to continue a research project beyond year 3 must submit a new request. If approved, a new HSIRB Protocol Number will be issued. The mailing or distribution of surveys or the collection of data may begin ONLY after this form has received committee approval (ALLOW 10 DAYS FOR PROCESSING) and has been properly filed with the HSIRB Representative or HSIRB Chairperson. It must have signatures of the Principal Investigator(s) or Faculty Sponsor. The Committee may, upon review of this application, deny the request for an exemption. To inquire about approval status, please contact the HSIRB Representative you submitted the application to or the HSIRB Chairperson. Revised 9/2019 67=M O   \ ^ _ e - 0 r s u y ߿߷ߔ߿zodhNOhVOJQJhNOhOJQJhNOhU5>*OJQJhNOhV5OJQJhVhOJQJhNOh5OJQJhNOhU5OJQJhUOJQJh56OJQJhh5OJQJh>*OJQJhOJQJh5OJQJhh5CJOJQJ'67L M ^ _ e f  & F () & F hj()j^j ()0^`0 ()^  () & F ()$a$f g Q ` a b r s $%& p!()` ()`^`` ()0^`0 ()^  & F ()  () TYe!"#$RSKL <=nprs?B=MӺӮϪϪhNOhUh5OJQJhh5OJQJh5OJQJhhOJQJhVhB*OJQJphhNOhVOJQJhNOhOJQJC&'Tas(RS p!()` p!()0^`0 p!() p!()`Sj-KL <=nop p!()` p!()0^`0 p!() p!()`p=> p!()p0^p`0 p!()`$a$gdNO p!()`^`` p!()0^`0DG#5<>*3Y_` QWmⱨhm[5OJQJhY?D5OJQJhAl5OJQJhs5OJQJhNOhU5OJQJh56OJQJh5CJOJQJhU5CJOJQJh{uhh6OJQJh5OJQJhOJQJ456*+^_ p@ !()@ `^@ `` p!() p!()p0^p`0 p!()`&kl8/ B!C!!";" p@ !()`gd p@ !()gd p@ !()gds p@ !()%&jklLOvw{  !C!i!!!!!"ȼȼЙІІЙ}umuaYhCJaJhhs>*䴳䴳s䴳s5Cϴssϴss5Oϴ5Oϴ5>*ϴ5Oϴϴsϴ󴡱5Oϴ5Oϴs5Oϴ5Oϴ""":";"<"|"""""#-#1#4#M#P#\#|###### $ $J$L$N$Q$R$S$T$g$h$i$7%8%9%_%%%˷˯˯˯˧˧˜ܓ|rghFVhY?DOJQJhCJOJQJh5CJOJQJhhOJQJh5OJQJhJhJOJQJhFVOJQJhOJQJhhJ5OJQJhUOJQJhJOJQJhJ5OJQJhU5OJQJhshCJaJhCJaJhsCJaJ(;"<"""N## $P$R$h$i$8%9%_% p@ !()` p@ !()]^ p@ !()gdFV p@ !()gdJ p@ !() p@ !()gdY?D _%%%%%%%&&'&(&c&d&&&&' p@ !()`gd3  H !$`') p@ !()` p@ !() p@ !()`gdFV%%%%%%%&&&'&(&)&*&+&c&d&&&M'`'b'''@)D))*5*a*b**+W+]+h+++++ؽܩ{nnnndhelCJOJQJh356CJOJQJh3h5CJOJQJh3h56CJOJQJh3h35>*CJOJQJhCJOJQJh3CJOJQJh3OJQJhFVhFVOJQJhY?DOJQJhhOJQJh5OJQJhU5OJQJhY?D5OJQJ%'c''')))+++  H !$`')  H !$`')gd3 +++++helCJOJQJhFVCJOJQJ(/ =!"#$% s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List ROR Default TextdCJOJQJkHT`T Y?D No Spacing$CJOJPJQJ_HaJmH sH tH 6U 6 Y?D0 Hyperlink >*B*phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< #N "%++ !$&f &Sp;"_%'+"#%8@0(  B S  ?$~Text26~Text5~Text3~Text23~Text24~Text9~Text10~Text11~Check6~Check7~Check3~Check4~Check5~Text12~Text13~Text14~Text15~Text16~Text17~Text18~Text19~Text20~Text21~Check8~Check9~Check10~Check11~Check12~Check13~Check14~Check15~Check16~Check17~Check18~Check19~Check20pqrQ J  ; m > 6+#  !"#pqrQ J  ; m > 6+#   ##9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType #vwJQ"9C07PV#3333333333%&k  ##%&k  ##&$*??4;'A wW($*/dh /y4hh^h`5o(. 0^`056o(.hh^h`>*o(.0^`0>*o(. hh^h`5>*o(.hh^h`>*o(.hh^h`5o(.wW??&$;'Ah/y/dUAlL Y?DNOm[els3{uFVVJ##@#@UnknownG.[x Times New Roman5Symbol3. .[x ArialWTms RmnTimes New Roman7.*{$ CalibriA$BCambria Math"cycyqUVl@Vl@&24##KQHP ?L 2!xx` NICHOLLS STATE UNIVERSITY+This for adapted from Texas Tech UniversityNicholls State UniversityJ Robert Field(       Oh+'0  $0 P \ h tNICHOLLS STATE UNIVERSITYӰɴý Normal.dotmJ Robert Field4Microsoft Office Word@xA@v@*ߧi@\iVl ՜.+,0 hp|  NSU@# NICHOLLS STATE UNIVERSITY Title  !"#$%&')*+,-./0123456789:;=>?@ABCEFGHIJKNRoot Entry FIiP1Table(?'WordDocument*NSummaryInformation(<DocumentSummaryInformation8DCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q