Human Participants Student Questionnaire Template

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Human Participants Form (4)
Required for all research involving human participants not conducted at a Registered Research Inst.
(IRB approval required before experimentation.)
Student’s Name(s)
Title of Project
Adult Sponsor
Contact Phone/Email
Must be completed by Student Researcher(s) in collaboration with the Adult Sponsor/Designated Supervisor/Qualified
Scientist:
1.
I have submitted my Research Plan which addresses ALL areas indicated in the Human Participants Section of the Research
o
Plan Instructions.
2.
I have attached any surveys or questionnaires I will be using in my project.
o
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. o Yes o No
Are you working with a Qualified Scientist?
Name:
Degree:
Email Address/Phone Number:
Experience/Training as it relates to this project:
Must be completed by Institutional Review Board (IRB) after review of the research plan.
The submitted
Research Plan must address all areas indicated on the Human Participants section of the Research Plan Instructions.
Check one of the following:
o
Research project requires revisions and is NOT approved at this time. IRB will attach document indicating
concerns and/or requested revisions.
o
Research project is Approved with the following conditions below: (All 5 must be answered)
1. Risk Level (check one) :
o
Minimal Risk
o
More than Minimal Risk
2. Qualified Scientist (QS) Required:
o
Yes
o
No
3. Written Minor Assent required for minor participants:
o
Yes
o
No
o
Not applicable (No minors in this study)
4. Written Parental Permission required for minor participants:
o
Yes
o
No
o
Not applicable (No minors in this study)
5. Written Informed Consent required for participants 18 years or older:
o
Yes
o
No
o
Not applicable (No participants 18 yrs or older in this study)
IRB SIGNATURES (All 3 signatures required) 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 and agree with the above IRB determinations.
Medical or Mental Health Professional
(a psychologist, psychiatrist, medical doctor, licensed social worker,
licensed clinical professional counselor, physician’s assistant, or registered nurse)
Printed Name
Degree/Professional License
Signature
Date of Approval
School Administrator
Printed Name
Degree/Professional License
Signature
Date of Approval
Educator
Printed Name
Degree/Professional License
Signature
Date of Approval
International Rules: Guidelines for Science and Engineering Fairs 2011-2012,
Page 35

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