Information that will need to be provided to the Institutional Review Board for consideration of an application. THIS IS NOT THE ACTUAL FORM. YOU MUST OBTAIN THE FORM BY CLICKING  HERE.





Name of Principal Investigator

Name of Faculty Sponsor (If PI is a student)

Institution                                                       Department

Campus Address

Campus Phone                                               Home Phone

E-Mail Address

Funding Agency (if applicable) 





Type of Review Requested: Full, Expedited, Exempt


Project Title    


Purpose:      Provide a brief description that describes the purpose of this research.


Subject selection:

a. Who will be the subjects? How will you enlist their participation? If you plan to advertise for subjects, please include a copy of the advertisement. Will subjects be remunerated in any way, and if so, how?

b. Will the subjects be selected for any specific characteristics?

c. State why the selection will be made on the basis or bases given in 2(b).

d.  Discussion of whether participants include any of the following populations: Fetuses, Hospitalized Patients, Institutionalized Patients,  Mentally Disabled, Mentally Retarded, Minors, Pregnant,  Prisoners.

e. Degrees of physical risk and psychological risk.


Procedures:     What precisely will be done to the subjects?  Explain in detail your methods and procedures in terms of what will be done to subjects.   Discuss design, instrumentation, and data collection. If you are using a questionnaire or handout, please include an electronic copy.


Risks and Benefits:     Are there any risks to the subjects? If so, what are these risks? What potential benefits will accrue to justify taking these risks?


Confidentiality:     Adequate provisions must be made to protect the privacy of subjects and to maintain confidentiality of identifiable information. Explain how your procedures accomplish this objective.


Information and Consent Forms:  State specifically what information will be provided to the subjects about the investigation.  Is any of this information deceptive?  State how the subjects’ informed consent will be obtained.   Include the consent form that you propose to utilize.  Consent forms should be limited to one page, whether letter or legal size; if longer, please add a signature and date line to each page and number of pages, e.g., “1 of 2,”  “2 of 2.”