Human Participants Student Questionnaire Template
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1Human Participants Form (4)
Required for all research involving human participants not at a Regulated Research Institution. If at a Regulated Research Institution,
use institutional approval forms for documentation of prior review and approval.
(IRB approval required before experimentation.)
Student’s Name(s)
Title of Project
Adult Sponsor
Phone/Email
Must be completed by Student Researcher(s) in collaboration with the Adult Sponsor/Designated Supervisor/Qualified Scientist:
1.
o
I have submitted my Research Plan/Project Summary which addresses ALL areas indicated in the Human Participants Section of
the Research Plan/Project Summary Instructions.
2.
o
I have attached any surveys or questionnaires I will be using in my project or other documents provided to human participants.
o Any published instrument(s) used was /were legally obtained.
3.
I have attached an informed consent that I would use if required by the IRB.
o
4.
Yes
No
Are you working with a Qualified Scientist? If yes, attach the Qualified Scientist Form 2.
o
o
BELOW ‑ IRB USE ONLY
Must be completed by Institutional Review Board (IRB) after review of the research plan. All questions must be answered for the
approval to be valid. (If not approved, return paperwork to the student with instructions for modifications.)
o
Approved with Full Committee Review (3 signatures required) and the following conditions: (All 6 must be answered)
1.
Risk Level (check one) :
Minimal Risk
More than Minimal Risk
o
o
2.
Qualified Scientist (QS) Required:
o
Yes
o
No
3.
Designated Supervisor (DS) Required:
Yes
No
o
o
4.
Written Minor Assent required for minor participants:
o
Yes
o
No
o
Not applicable (No minors in this study)
5.
Written Parental Permission required for minor participants:
o
Yes
o
No
o
Not applicable (No minors in this study)
6.
Written Informed Consent required for participants 18 years or older:
Yes
No
Not applicable (No participants 18 yrs or older in this study)
o
o
o
o
Approved with Expedited Review (1 signature required). Study involves either of the following:
Human participants will only provide feedback on project design/student-designed invention or prototype. etc., no personal
o
data will be collected and there are no health or safety hazards.
Student is the only subject of the research and no more than minimal risk is involved.
o
IRB SIGNATURES (All 3 signatures required unless expedited review checked above) None of these individuals may be the adult
sponsor, designated supervisor, qualified scientist or related to (e.g., mother, father of) the student (conflict of interest).
I attest that I have reviewed the student’s project, that the checkboxes above have been completed to indicate the IRB determination
and that I agree with the decisions above.
Medical or Mental Health Professional (a psychologist, medical doctor, licensed social worker, licensed clinical professional counselor, physician’s
assistant, doctor of pharmacy, or registered nurse) with expertise related to this project.
Printed Name
Degree/Professional License
Signature
Date of Approval (Must be prior to experimentation.)
Educator
Printed Name
Degree
Signature
Date of Approval (Must be prior to experimentation.)
School Administrator
Printed Name
Degree/Professional License
Signature
Date of Approval (Must be prior to experimentation.)
Page 36
International Rules: Guidelines for Science and Engineering Fairs 2017 – 2018,
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