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Mary Immaculate College Research Ethics Committee

MIREC-3: Application Form

Instructions:

  1. Complete all relevant sections of this form.The information provided must be comprehendible to non experts.
  2. Attach a copy of all relevant documentation to the application. Failure to provide the necessary documentation will delay the consideration of the application.
  3. If the applicant is a Research Postgraduate Student their Supervisor(s) must sign Section 4 of this form.

1a / Title of Research Project
1b / Brief Outline
2 / Proposed Start Date / Month / Year
Anticipated Completion Date / Month / Year
3 / Project Investigators
3a / Principal Investigator
Name
Faculty
Department
Position / Subject:
Qualifications
E-mail: / Phone:
3b / Other Investigators (use additional sheet if necessary)
Name / Qualifications & Affiliation / Signature
3c / Foresight
3d / Ethical Guidelines / Ethical Clearance from Another Source
Are there Ethical Guidelines to which you must adhere in your field of study?
If yes, please specify below: / Yes / No
Do you require Ethical Clearance from another source?
If yes, please specify below: / Yes / No
4 / Supervisor(s)
To be completed in cases where the applicant is a research postgraduate student.
I hereby authorise the Principal Investigator named above to conduct this research project in accordance with the requirements of MIREC-6 and I have informed the Principal Investigator of their responsibility to adhere to the recommendations and guidelines in MIREC-6.
Name / Department / Date / Signature
5 / Study Descriptors
Please mark the terms that apply to this research project with a 
Healthy Adults / Vulnerable Adults
Children (< 18 yrs) / Vulnerable Children (<18yrs)
Physical Measurement / Psychological Measurement
Video Recording/Photography / Voice recording
Questionnaire/Interview / Observational
Physical Activity / Record Based
Project is Off-Campus / ‘Other’ descriptor(s) not named here
Please specify ‘Other’ descriptor(s)
6 / Project Design and Methodology
6a / Rationale, Purpose and Benefits of Research Project
6b(i) / Research / Data Collection Techniques
6b(ii) / Research Methodology
6c / Steps taken to Minimise Risk
6d / Location(s) of Project
6e / Questionnaires and Interview/Survey Questions
7 / Participants
7a / How will potential research participants be identified and selected?
7b / To be completed in cases where the applicant intends to recruit students that they teach as research participants.
Does the proposed research necessitate the participation of your current student cohort? / Yes / No
If you have indicated that the proposed research necessitates the participation of students that you teach please provide:
A rationale as to why it is necessary that students that you teach participate in the research.
Details of the steps you will take to ensure that participation is voluntary and that participants may withdraw at any time without consequence or fear of consequence.
7c / How many participants will be recruited?
7d / Will participants be reimbursed for taking part in this research project?
If YES, please attach the details to this application. / Yes / No
7e / Will incentives / inducements be provided to participants for taking part in this research project?
If YES, please attach the details to this application. / Yes / No
7f / Will Recruitment Letters/Advertisements/e-mails, etc. be used to recruit participants?
If YES, please attach the details to this application. / Yes / No
7g / Will a permission form be used to document permission to conduct the research within an institution?
If YES, please attach the details to this application. / Yes / No
8 / Confidentiality of collected data and completed forms (e.g. informed consent)
8a / What measures will be taken to ensure confidentiality of collected data?
8b / Where and how will the data be stored / retrieved?
8c / Who will have custody of, and access to, the data?
8d / For how long will the data from the research project be stored? (Please justify)
9 / Information Documents
Indicate which of the following information documents are applicable to your Research Project by ticking either Yes or No in the checklist below. Attach a copy of each applicable information document to the application.
Applicable Please 
Documents / Yes / No
Participant Information Sheet
Parent/Responsible Other Information Sheet
Participant Informed Consent Form
Parent/Responsible Other Informed Consent Form
Questionnaire (or sample)
10 / Declaration

The information in this application form is accurate to the best of my knowledge and belief, and I take full responsibility for it. I undertake to abide by the ethical principles outlined in the MIC Research Ethics Committee guidelines. If the research project is approved, I undertake to adhere to the study protocol without unagreed deviation, and to comply with any conditions sent out in the letter sent by the MIC Research Ethics Committee notifying me of this. I undertake to inform the MIC Research Ethics Committee of any changes in the protocol. I accept without reservation that it is my responsibility to ensure the implementation of the guidance of MIREC as outlined in MIREC-6.

Name (Print) ______Signature ______Date ______

MIREC-3 Rev 7 / Page 1 of 3