IRB Form

INSTITUTIONAL REVIEW BOARD

CALIFORNIA STATE UNIVERSITY SAN BERNARDINO

Application to Use Human Participants in Research


1. PROJECT REVIEW
X New Project (ID# will be assigned by the IRB)
o Revised Project (Enter IRB ID#)
o Renewal (Enter IRB ID#)
Approximate date of most recent previous review of this project _____________

2. DATA COLLECTION DATES: From __5_/_20__/_06__ To __5_/_22__/_06__
This is required information, must be future dates - after you have received final IRB approval to conduct your research.

3. INVESTIGATOR(S) NAME(S) _Robert Earl Lynn
Department: Education-_Instructional Technology_____
Phone ___(951) 763-0805___________________
Student(s)/Researcher(s) E-mail Address(s): __________________________________
If you are a student, please provide the following information:
This research is for o Graduate Thesis & Projects o Honors Project
o Independent Study o Course ___________
o Other ____________

4. PROJECT TITLE__
Hamilton Middle School Website__________________________________
________________________________________________________________

5. DESCRIPTION OF PARTICIPANTS (Enter approx. no. of participants and categories that apply)
Number __150______ Gender: x Female x Male
o CSUSB Students x Children (17 or younger) o Child Development Center
o Prisoners o Patients in institutions o Pregnant Women
o Other _________________

6. IS FUNDING BEING SOUGHT FOR THIS RESEARCH?
o Yes x No
If yes, you must submit one complete copy of that proposal as soon as it is
available and respond to the following questions:

Does the funding agency require notification of Institutional Review Board approval? o Yes o No
(If yes, please provide the IRB Secretary with one copy of all relevant forms, instructions, etc., with your original copy of this application.)

Project period from ______________ to _______________
7. INDICATE THE REVIEW CATEGORY FOR WHICH YOU ARE APPLYING.

o I am applying for exempt review, based on the following category (ies):
(Check all that apply. Submit an original and one copy of all application materials to the IRB.) Note: Research involving children must be reviewed FULL BOARD.

o Research conducted in established or commonly accepted educational settings and involving normal educational practices
o Research involving the use of educational tests, if information from these sources is recorded in such a manner that participants cannot be identified in any way
o Research involving survey or interview procedures where participants cannot be identified
o Research involving the observation of public behavior where participants cannot be identified
o Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, where these sources are publicly available or where participants cannot be identified

o I am applying for expedited review, based on the following category(ies):
(Check all that apply. Submit an original and 1 copy of all application materials to the IRB.)

o Collection of hair, nail clippings, teeth in a non-disfiguring manner.
o Collection of excretal and/or external secretions.
o Recording of data from adults using noninvasive procedures.
o Collection of moderate levels of blood samples from adults in good health.
o Collection of supra- and sub-gingival dental plaque and calculus.
o Voice recordings made for research purposes.
o Moderate exercise by healthy volunteers.
o Study of existing data, documents, records, or pathological or diagnostic specimens.
o Non-manipulative, non-stressful research on group or individual behavior.

x I am applying for full board review.
(Submit an original and 1 copy of all application materials to the IRB.)

8. ATTACHMENTS. I have included copies of all relevant project materials and documents, including (check all that apply):

Surveys, questionnaires, and/or interview instruments.
x Informed consent forms or statements.
o Letters of approval from cooperative agencies, schools, or education boards.
o Debriefing statements or explanation sheet.
o Participant recruitment materials, including flyers and advertisements.




9. AFFIRMATION OF COMPLIANCE:
I agree to follow the procedures outlined in the summary description and any attachments to ensure that the rights and welfare of human participants in my project are properly protected. I understand that the study will not commence until I have received approval of these procedures from the IRB or where appropriate a department Human Participants Review Board; I have complied with any required modifications in connection with that approval. I understand that additions to or changes in the procedures involving human participants, or any problems with the rights or welfare of the human participants must be promptly reported to the IRB. I further understand that if the project continues for more than one year from the approval date, it must be re-submitted as a renewal application.
*NOTE: You (the investigator/researcher) are required to notify the IRB if any substantive changes are made in your research prospectus/protocol, if any unanticipated adverse events are experienced by subjects during your research, and when your project has ended. Important: If your project lasts longer than one year, you (the investigator/researcher) are required to notify the IRB by email (mgillesp@csusb.edu) or correspondence of Notice of Project Ending or Request for Continuation at the end of each year. Failure to notify the IRB of the above may result in disciplinary action. You are required to keep copies of the informed consent forms and data for at least three years.

*(Required for all investigators):
I affirm the accuracy of this application, and I accept responsibility for the conduct of this research, the supervision of human participants, and maintenance of informed consent documentation as required by the IRB.
_______________________________ mightyduck1984@yahoo.com 4/30/06

Signature of Investigator Your e-mail address Date

________________________________ ________________________ _________________
Signature of Co-Investigator(s) Your e-mail address Date

APPROVAL OF FACULTY ADVISOR/SPONSOR
*(Required for all faculty advisors) By signing - you as faculty advisor affirm the accuracy of your students application and accept responsibility for the conduct of this research, the supervision of the researcher (student) in ethical conduct of research, and maintenance of informed consent documentation as required by the IRB.

_________________________________ _________________ _____________________________
Printed Name of Faculty Advisor/Sponsor Campus Phone E-mail of Faculty Advisor

_________________________________ _________________
Signature of Faculty Advisor/Sponsor Date

APPROVAL OF A LICENSED PHYSICIAN (Required only if the project involves medical procedures and neither the investigator nor the faculty/advisor is a licensed physician)
________________________________ _________________
Printed Name of Licensed Physician Contact Phone

_________________________________ _________________
Signature of Licensed Physician Date
Please Re-type the headings and answer in your own words (given below in boldface type) for questions 10 through 15 and use as many separate sheets of paper as you need to respond fully. DO NOT COPY THESE PAGES AS PART OF THE APPLICATION. Attach the appropriate forms as requested in 14 and 15.

10. PARTICIPANT RECRUITMENT.
I will be using the information gathered from surveys of the Hamilton Middle School students who are in the 6th and 7th grades. My contact with the students will be minimal as I am going to request that the computer lab teacher deliver the survey and collect them after the survey is complete. All contact will be conducted at the school site during normal school hours and will be done anonymously. The students are divided equally by gender, and are between 11 and 13 years old.
11. PROJECT DESCRIPTION.
As this project’s design is to assist in the communication among staff, parents, and students of Hamilton Middle School, I am going to request that the students assist during the alpha and beta stages of the project. The purpose is to receive helpful feedback from the students related to the ease of use and relevance in achieving the desired level of communication. The survey will simply be a line piece of paper in which the student will write their findings of the project. My project will be located on my personal domain on the Internet so that it may be viewed at Hamilton as well as remote sites. The computer teacher will instructed the students not to put their names or other personal information on the survey; only the findings about the project. Minimal contact with the students will be necessary as it will be conducted during the normal computer lab time and only for two 54 minute periods.
12. CONFIDENTIALITY OF DATA.
All information will be strictly confidential and will not include names or other personal information .To insure this is followed, the computer teacher will read the informed consent statement prior to having the students conduct their survey. Also, I will check that no student did in fact place their name on the survey, if so, I will remove the name.
13. RISKS AND BENEFITS.
As the interaction with the students will be minimal and will not require any personal information, there are no risks involved.

14. INFORMED CONSENT.
Before delivering the survey to the students, the computer lab teacher will read the informed consent statement to the students (see attached statement). This will be delivered orally to the students.

15. DEBRIEFING STATEMENT.
Since no method of deception was used during this survey, a debriefing statement will not be necessary. However, I will personally thank the students for their participation in helping develop their school’s Website.

Informed Consent

The survey in which you are being asked to participate is to investigate the design process and test a Website’s ability to communicate among teachers, parents, and students. This survey is being conducted by Mr. Lynn (Robert Lynn) under the supervision of Dr. Baek Professor of Education in Instructional Technology. This survey has been approved by the Institutional Review Board, California State University, San Bernardino.

Informed Consent Statment
In this survey, you will be asked to view the Hamilton Middle School Website prototype at Lynntribe.com. You will then be asked to write on a lined piece of paper your findings of the prototype. This will take two class periods consisting of 54 minutes each. All of your responses will be held in the strictest of confidence by the researcher. Your name will not be reported with your responses. All data will be reported in group form only.

Your participation in this survey is strictly voluntary. You are free not to answer any questions and withdraw at any time during this survey without penalty.

If you have any questions or concerns about this survey, please feel free to contact Dr. Baek at (909) 880-5000 extension 75454.