Application For Exemption From Institutional Oversight

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Application for Exemption from Institutional Oversight
Unless qualified as meeting the specific criteria for exemption from Institutional Review Board (IRB) oversight, ALL LSU research/
Institutional Review Board
projects using living humans as subjects, or samples, or data obtained from humans, directly or indirectly, with or without their
Dr. Robert Mathews, Chair
consent, must be approved or exempted in advance by the LSU IRB. This Form helps the PI determine if a project may be exempted,
130 David Boyd Hall
and is used to request an exemption.
Baton Rouge, LA 70803
Applicant, Please fill out the application in its entirety and include the completed application as well as parts A-F, listed
P: 225.578.8692
F: 225.578.5983
below, when submitting to the IRB. Once the application is completed, please the completed application to the IRB Office
or to a member of the Human Subjects Screening Committee. Members of this committee can be found at
A Complete Application Includes All of the Following:
(A) A copy of this completed form and a copy of parts B thru F.
(B) A brief project description (adequate to evaluate risks to subjects and to explain your responses to Parts 1&2)
(C) Copies of all instruments to be used.
*If this proposal is part of a grant proposal, include a copy of the proposal and all recruitment material.
(D) The consent form that you will use in the study (see part 3 for more information.)
(E) Certificate of Completion of Human Subjects Protection Training for all personnel involved in the project, including students who are
involved with testing or handling data, unless already on file with the IRB. Training link: ( )
(F) IRB Security of Data Agreement: (
1) Principal Investigator:
2) Co Investigator(s): please include department, rank, phone and e-mail for each
IRB#___________ LSU Proposal #_________
*If student, please identify and name supervising professor in this space
Complete Application
Human Subjects Training
IRB Security of Data Agreement
3) Project Title:
4) Proposal? (yes or no)
If Yes, LSU Proposal Number
Also, if YES, either
This application completely matches the scope of work in the grant
More IRB Applications will be filed later
5) Subject pool (e.g. Psychology students)
*Circle any "vulnerable populations" to be used: (children <18; the mentally impaired,
pregnant women, the ages, other). Projects with incarcerated persons cannot be exempted.
6) PI Signature
(no per signatures)
** I certify my responses are accurate and complete. If the project scope or design is later changes, I will resubmit for review. I will
obtain written approval from the Authorized Representative of all non-LSU institutions in which the study is conducted. I also
understand that it is my responsibility to maintain copies of all consent forms at LSU for three years after completion of the study. If I
leave LSU before that time the consent forms should be preserved in the Departmental Office.
Screening Committee Action: Exempted ______ Not Exempted _____ Category/Paragraph _____
Signed Consent Waived?: Yes / No
Reviewer _________________________ Signature _____________________________ Date ___________


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