Human Subject Review Protocol

The West Liberty University Human Subjects Committee for the Protection of Human Subjects

1. Principal Investigator

Name (required)



Email (required)

Date of Submission:

2. Co-Investigators

3. Project Title:

4. Type of Project:

Dates during which project will be conducted:

5. Project Funding Source:

IRB Protocol

The research questions and hypotheses for the following study are:



Appendix A

Please attach your survey:

Appendix B

Please attach your Informed Consent form:

The following is an example of an Informed Consent form:

Dear citizen,

My name is ……. and I am a …………. at West Liberty University and reside locally in your community. I am currently collecting data………………. You are invited to participate in this research study because …………………... The information I wish to obtain pertains ……………………

The survey should take approximately ….. minutes of your time, and participation is completely voluntary. You are free to decide not to participate in this study. There is no penalty for choosing not to complete the survey. Some of the survey items may pertain to you recalling emotional events in your life and may be sensitive in nature (for instance if you were a victim of crime). Because of this, if at any time during the completion of the survey you feel you must refrain from completing the survey, simply hand the survey in and you are free to leave. Please keep this informed consent form with the accompanying information in case you feel the need to contact the researcher, or any accompanying agency.

There will be no identifying information recorded when you complete the survey. Please refrain from putting your name or any identifying information on the survey. All data will be collected to comply with research standards protecting the identity of the research participants. The data will be collected for the purpose of identifying the goals stated above. You may reach me ……. Or with any questions you may have.

Your name:_________________________________________

Additions to or changes in procedures involving human subjects as well as any problems connected with the use of human subjects once the project has begun must be brought to the attention of the WLU Human Subjects Committee.

I agree to provide whatever surveillance is necessary to ensure that the rights and welfare of the human subjects are properly protected. I understand that I cannot initiate any contact with human subjects before I have received approval/or complied with all the contingencies made in connection with the approval. I understand that as the principal investigator I am ultimately responsible for the welfare and protection of human subjects and will carry out the project as approved.

Signature of Principal Investigator/Program Director / Date

By signing below I am confirming that I am voluntarily participating in the aforementioned survey.

Printed Name of Participant / Date

Signature of Participant / Date



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