RESEARCH ETHICS BOARD

REQUEST FOR INSTITUTIONAL APPROVAL

COMPLETE THIS APPLICATION IF YOU ARE AFFILIATED WITH ANOTHER INSTITUTION AND REQUIRE APPROVAL TO CONDUCT RESEARCH INVOLVING NIPISSING UNIVERSITY STUDENTS, STAFF, FACULTY MEMBERS OR USING NIPISSING UNIVERSITY FACILITIES.

For Administrative Use Only

Date Received: / Host Institution: / Date Approved: / Approval #

IMPORTANT PLEASE READ: All relevant sections of this form must be completed. Attached documents may not be used instead of the standard form(s). Applications must be submitted by the deadline date noted on the Research Ethics Board website, in order to be reviewed in that month and at least 8 weeks in advance of the project start date. Allow 4 to 6 weeks for the Research Ethics Board to respond. Reviews are conducted according to the principles and spirit of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. Applicants are advised to familiarize themselves with this document.

Any personal information collected on this form will form part of the records held in the Research Services Office and will be used to assist in the administration of your research program. A copy of this form may be reviewed by external parties in order to meet legislative, audit and/or regulatory requirements. If you have any questions or concerns about the information collected, please contact the Ethics Coordinator at 705-474-3450 ext. 4055.

1.0APPLICANT (Principal Investigator)

THE TCPS 2 ONLINE TUTORIAL MUST BE COMPLETED PRIOR TO PROTOCOL SUBMISSION. Please visit
Have you completed the TCPS2 tutorial: YES - I have attached my Certificate of Completion
Please provide your permanent mailing address (including postal code): / Department /Faculty
Name:
Address:
E-mail Address:
Telephone Number (daytime):

1.1

Title of Research Project:
Proposed Start Date of Research: / Proposed End Date of Research:

1.2

NAME AND CONTACT INFORMATION / Department
Co-Investigator(s)
Faculty Supervisor (in the case of student research)

Please choose one of the following that pertains to you:

Faculty Researcher

Administrative Researcher

Undergraduate Student Researcher

Graduate Student Researcher

2.0 SIGNATURES

Principal Investigator Assurance:

I certify that the information provided in this protocol is complete and accurate. I understand that I have ultimate responsibility for the conduct of the study, the ethics performance of the project, and the protection of the rights and welfare of research participants. I agree to comply with the Tri-Council Policy Statement and NipissingUniversity policies and procedures governing the protection of human participants in research. I will not make changes to this protocol without notifying the REB of the proposed changes and seeking its prior approval.

Signature of Principal InvestigatorDate

Faculty Supervisor Assurance: For student applications

I have read this protocol and deem it to be complete. I understand if this application is incomplete it will be returned to me and I will be responsible for ensuring its completion. The project is valid and worthwhile. I agree to provide the necessary supervision of the student(s) and to make myself available to the student(s) should problems arise during the course of the research.

Signature of Faculty SupervisorDate

3.0 FUNDING STATUS OF PROJECT

Unfunded

External Agency/Sponsor Funded Applied for

SSHRC NSERC CIHR Other (please specify):

Period of Funding From: To:

Comments (optional):

3.1OTHER RESEARCH BOARD APPROVAL

Research conducted in different research jurisdictions must be reviewed by different bodies when they, or their equivalents, exist. In all cases, review is still required by the REB within the researcher’s home institution. Please provide a copy of the host/home institutions protocol, including all attachments and REB approval(s) receivedto this application.

a)Is this a multi-centred study (more than one institution is involved)?Yes No

(i) If Yes,name the other institution(s) involved.

b)Is this project under review by any other institutional Ethics Board?Yes No

(i) If Yes, name the other institution:

PLEASE COMPLETE AND SUBMIT ONE (1) SIGNED ORIGINAL AS WELL AS ONE (1) ELECTRONIC VERSION OF THIS PROTOCOL TO:

Ethics Coordinator

ROOM F309

Fax: (705) 474-5878

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Institutional AuthorizationJun2013