Application for Ethical Review ofpage 1 of 6

Course-based Research in TSE

Course-based research
involving human subjectsrequires this application.

Instructions

  1. Please Complete thisapplicationelectronically (PDF), or by hand(using a printed copy).
  2. All applicantsanswer all questions insectionsA, B, and D of this application.
  3. If your research involves interviewing human subjects, also complete sectionC(page 4).
  4. Send this completed application to the Chair of the TSE Ethics Committee, Professor David Holdsworth:

Address:
David Holdsworth
Chair, Ethics Committee
School of the Environment
1600 West Bank Dr., Peterborough, ON K9L 0G2 / Mailbox Location (for hand delivery):
TSE Office, ESC C202
FAX:705-748-1569
Email:

Once your application is received and reviewed, a member of the School of the Environment Ethics Committee will contact you.

Section A. Student ResearcherContact Information

1.Name:
2.Email Address:
3.Are you a Trent undergraduate student? / Yes No
4.Trent Department/Program:
5.Phone Number (with area code):
6.Fax Number (if applicable;with area code):

Section B. Research Project Information

1. Title of Research Project:
2.Course Code and Term (e.g., ERST 4901H 2016FA)
3.Trent University supervisor Name:
4.Host Organization Name (if applicable):
5.Host Supervisor Name (if applicable):
6.Expected Research Start Date (yyyy-mm-dd):
7.Expected Research End Date (yyyy-mm-dd):

Section B. (continued)

8.Brieflydescribe of your research design, including sample survey questions as appropriate. Pay special attention to the details of your intervention.

9.Will you be using live vertebrates or cephalopods in your research? Yes No

If yes, you will have to submit an animal care protocol to the Trent Animal Care Committee( and have it approved, before your research can proceed. Speak with your supervisor, as he/she may already be arranging this.

10.A.Will your project involve research that is focussed on aboriginal peoples? Yes No

B.If yes, has it been reviewed by the Aboriginal Education Council? Yes No

11.Estimated number of human subjects required:
12.Source of human subjects:

13.A.Will any of the human subjects be children? Yes No

B.If yes, has the assent of the children and their informed consent of the parent(s) or
guardian(s) been obtained? Yes No

14.A.Will anyhuman subject of any age be recruited in an institution that has authority over
the subject (e.g., school, hospital, prison, seniors home, etc.)? Yes No

B.If yes, explain what steps will be taken to obtain consent of the institution and to ensure that consent of the subject is freely given. If consent of the institution cannot or should not be obtained, explain (e.g., research about corporation or governments does not require their consent).

Section B. (continued)

15.Human Subject Risk

A1.Do you consider that your research might expose the human subjects to increased risk to physical or mental health? Yes No

A2.If yes, provide details and rationale or justification.

B1.Do you consider that your research might expose the human subjects to increased risk to reputation, financial status, or privacy? Yes No

B2.If yes, provide details and rationale/justification.

C.Ifyour research will involve either or both of the above two types of risk
(i.e., answered Yes to either or both 15A1 and 15B1):

Explain how the human subjects will be informed of the risks before consenting to participation, how adverse results will be reported, and why the potential benefits of your research exceed the risks.

16.What incentives, if any, will be provided to the human subjects?

Section C.Statement of Intent Concerning theInterviewing of Human Subjects

Signed, free and informed consent to use human subjects in research is normally required in advance, unless the nature of your research prevents it (e.g., telephone surveys).

If your research involves interviewing human subjects, you must complete this section.
Otherwise, proceed to section D.

1.How will informed consent be obtained?
(choose one) / by each subject signing a consent form
verbally after subjects have read (or have been read) a consent form
by written communication to subjects after they have agreed to be interviewed. Such a communication should contain the same information as a standard consent form/statement
other (describe):
2.What level of privacy / confidentiality / anonymity is promised to subjects?
(choose one) / none
names and identifying information may be used in the final report, but subjects will be given the opportunity to review the report and consent to the inclusion of such information in the final report
names and identifying information will not be used in the final report, but will be part of the raw data and will be known to the researcher
names and identifying information will not be used in the final report, and will not be part of the raw data, but will be known to the researcher
names and identifying information will not be used in the final report, will not be part of the raw data, and will not be known to the researcher
other (describe):

Section C. (continued)

3.How will the raw data be handled and stored during and after the research, particularly in order to ensure any above-mentioned confidentiality?

4.A.Deception and Delayed Disclosure: Will any form of temporary deception, or partial or
delayed disclosure be used?YesNo

B.If yes, explain why.

5.A.Other Data Collectors:
Will anybody other than the applicant be used to collect data?YesNo

B.If yes, explain how they will be made to comply with the ethical research standards.

6.Research Follow-Up

A.Describe any research-related follow-up with research subjects after the completion of data collection.

Section C. (continued)

6.Research Follow-Up (continued)

B1Will you make your research results accessible to the research subjects?
YesNo

B2If yes, how?

7.Will the police at the physical location of your research be informed of your survey plans?
YesNo

Section D. StudentResearcher Acknowledgement

I, the applying student researcher, have completedall the questions on this applicationtruthfully, to the best of my ability (check box at left).
Date (yyyy-mm-dd)

Please submit this completed application to the head of Chair of the TSE Ethics Committee, as described at the beginning of this document.

Thank you.