BISHOP’S ETHICS SUBMISSION FORM

FOR RESEARCH INVOLVING HUMAN PARTICIPANTS

FOR FACULTY AND GRADUATE STUDENTS

Researchers should submit their submission package (PDF file including the form, duly signed and dated, and the required appendices) to the Research Office by email (). You can consult Bishop’s Research Ethics Policy on the University website and the Tri-Council Policy Statement Ethical Conduct for Research Involving Humans at:

It is mandatory to complete all sections. If a section does not apply, you must insert N/A.

1.Investigator
Name
Department
Division/School
Phone
Email
Co-Investigator
Name
Department
Division/School
Phone
Email
2.Research Supervisor (if applicable)
Name
Department
Division/School
Phone
Email
3. Type of Research (select one)
☐ Teaching exercise (class group project)
☐ Honours thesis
☐ Professor’s research
☐ Postgraduate research
☐ Other, specify:
4.Research Project
  1. Title of the Research Project

  1. Anticipated Start and End Dates of the Project
Research work with human participants must not begin before REB approval.
Start date:Click here to enter a date.
End date: Click here to enter a date.
  1. Funding Source

☐ Provincial (FRQSC, FRQNT, FRQS)
☐ Federal (NSERC, SSHRC, CIHR)
☐ Internal (Senate Research Committee)
☐ Other, specify:
☐ Does not apply
  1. Multi-Study Projects

Is this protocol part of a multi-study project funded internally or externally?
☐ Yes
☐ No
If yes, please indicate the title of the funded research project and the REB number of previously-approved studies or releases of funds for this project:
Title:
REB Number(s):
5. Research Protocol
  1. Summary of the Research Project(max.500 words)
  1. Explain in plain language the objectives of your project and its contributions to your field of research.

  1. Participants (max.250 words)
  1. Describe the research participants. Be as specific as possible by indicating the number of participants, their status, their age, and any other pertinent characteristics. For research involving minors (under 18) parental/guardian/authorized third party consent is required.

  1. If the research involves a particular group while excluding another on the basis of criteria such as gender or language, indicate why such exclusion is appropriate. (max. 250 words)

  1. Indicate how the participants will be chosen for this research. Submitas an appendix any poster, advertisement or letter used to recruit research participants.(max. 250 words)

  1. Research Methodology
  1. Outline what the participants will be required to do. Indicate the number and length of sessions in which each individual will participate.(max. 500 words)

  1. Are any questionnaires or other materials distributed or administered to the participants? If yes, submit the questionnaires as an appendix.

☐ No
☐ Yes
  1. Does the research involvequalitative interviews? If yes, submit questions as an appendix. If in development, provide sample questions.

☐ No
☐ Yes
  1. Are scientific instruments involving covert or physical contact used?If yes, provide a description of the apparatus, its function, and how it will be used (e.g. electrodes, sensory devices, etc.) as an appendix.

☐ No
☐ Yes
6. Free and Informed Consent
  1. Indicate how you will obtain the free and informed consent of research participants and, where applicable, of authorized representatives of participants who are not competent to give consent. For research involving minors (under 18) parental/guardian/authorized third party consent is required. Submit the consent form (and information sheet, if applicable) to be given to the research participantsas an appendix. For information on what must be included in the consent form, refer to the appropriatetemplate(see website).(max. 250 words)

  1. Consent and Secondary Use of Identifiable Information for Research Purposes
  1. If you use identifiable data from a previous project for secondary analysis, was consent originally obtained from participants for secondary use of identifiable information? If no, please answer question B.2.

☐ No
☐ Yes
☐N/A
  1. If you do not have consent, you must meet the following conditions for the secondary use of identifiable information (check all cases that apply).

☐Identifiable information is essential to research;
☐The use of identifiable information without the participants’ consent is unlikely to adversely affect the welfare of individuals to whom the information relates;
☐Appropriate measures are taken to protect the privacy of individuals, and to safeguard the identifiable information;
☐Any known preferences previously expressed by individuals about any use of their information are respected;
☐It is impossible or impracticable to seek consent from individuals to whom the information relates;
☐Any other necessary permission for secondary use of information for research purposes has been obtained.
  1. If these conditions are not met, explain why and specify what will be done. (max. 250 words)

7. Proportionality of Harms and Benefits
  1. Foreseeable Risks
  1. Does the research involve more than minimal risk (minimal risk refers to research in which the probability and magnitude of possible harms implied by participation in the research is no greater than those encountered by participants in the aspects of their everyday life that relate to the research)?(max. 250 words)

  1. Explain the methods used that might cause foreseeable inconveniences or harms to the research participants. Describe the potential legal, physical, psychological, social, behavioural or economic consequences associated with each procedure in the research. (max. 250 words)

  1. Describe the measures you have taken to eliminate or mitigate such risks. (max. 250 words)

  1. If partial disclosure (participants do not know the true purpose of the research in advance) or deception (participants are given false information) is used, justify its use.(max. 250 words)

  1. Indicate the measures you have taken to eliminate or mitigate risks associated with partial disclosure or deception.(max. 250 words)

  1. If partial disclosure or deception is used, participants must be debriefed. Specify below when the debriefing session will take place and providethe debriefing document(s)as an appendix.(max. 250 words)

  1. Potential Benefits
Justify the potential risks by describing the anticipated (direct and/or indirect) benefits of the research for both the research participants and for general knowledge. Specify how these benefits will be maximized.(max. 250 words)
8. Privacy of Research Participants
  1. Anonymity
  1. Specify what type(s) of information about participants will be collected and used (check all cases that apply).

☐Directly identifying information: information identifies a specific individual through direct identifiers (e.g. name, social insurance number, personal health number);
☐ Indirectly identifying information: information can reasonably be expected to identify an individual through a combination of indirect identifiers (e.g., date of birth, place of residence, unique personal characteristics);
☐ Coded information: direct identifiers are removed from information and replaced with a code. The principal investigator retains a list that links participants’ code names with their actual name so data can be re-linked if necessary;
☐ Anonymized information: information is irrevocably stripped of direct identifiers and no code iskept to allow future re-linkage;
☐ Anonymous information: information never had identifiers associated with it (e.g. anonymous surveys).
  1. For directly identifying information, indirectly identifying information, and coded information, specify the privacy risks, provide a justification for this and specify what measures will be taken to minimize these risks. (max. 250 words)

  1. For anonymized information and anonymous information, specify how the anonymity of research participants will be ensured. (max. 250 words)

  1. If participants are interviewed, state whether the interviewees will be quoted and whether their privacy will be ensured. If not, explain why, specify how they might be identified or their contribution recognized, and mention it in the consent form (and information sheet, if applicable).(max. 250 words)

9. Confidentiality of Data
  1. Security Measures to Safeguard Information
  1. Specify who will have access to the data collected.(max. 125 words)

  1. Specify where the data will be stored.(max. 125 words)

  1. Specify whether the data will be destroyed, and if so, when and how it will be destroyed. If not, specify what will be done to protect its confidentiality.(max. 125 words)

  1. Specify how information will be handled if participants choose to withdraw from the research.(max. 125 words)

  1. Potential Threats to the Security of Information
Specify if there are any risks to data security. If any, mention them in the consent form. For example, some online surveys, like “Survey Monkey”, are open to third party scrutiny and are therefore not secure. Survey Monkey is subject to the United States Patriot Act. If using it, include in the consent form the statement to that effect provided in the template Letter of Consent to Participate in a Research Project –Online Survey.(max. 250 words)
  1. Future Uses of Identifiable Information
Willidentifiable data collected in the current project be used for secondary analysis in future projects? If yes, it must be mentioned in the consent form.
☐ No
☐ Yes
  1. D. Future Uses of Non-Identifiable Information
Will non-identifiable data collected in the current project be used for secondary analysis in future projects? If yes, it must be mentioned in the consent form.
☐ No
☐ Yes
10. Attestation

I agree to abide by the ethical guidelines and procedures of Bishop’s University Research Ethics Board, of the Tri-Council Policy Statement, of my profession or discipline, as well as the institution in which the research is undertaken. I am aware of my responsibility to be familiar with these standards. I further agree to notify the Research Ethics Board of any change that affects participants at any stage of the research project. I agree to comply with requests made by such Board during this research project.

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Signature of InvestigatorDate

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Signature of Co-investigatorDate

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Signature of SupervisorDate

(When applicable)

Note: Unsigned and undated forms will not be reviewed by the Research Ethics Board.

Bishop's University | Revised May 2015 / 1