HSIRB APPLICATION FOR PROJECT REVIEW JOB AID
A new Application for Project Review must be submitted to the WMU HSIRB every three years. Verify with the BATS Manager that your system is eligible for this prior to completing this application.
II. PROJECT TITLE: System/project title
III. INVESTIGATOR INFORMATION
PRINCIPAL INVESTIGATOR OR ADVISOR
Name: Richard Malott
Department: Psychology
Title: Professor
Degree Attained: Ph.D.
Email Address:
Street or Campus Address: 8971 W. KL Ave
City: Kalamazoo
State: MI
ZIP: 49009
Office Phone: (269) 387-4491
Home Phone: (269) 372-1268
Human Subjects web training at completed: Yes
Status and level of involvement of student investigator: Master level
CO-PRINCIPAL OR STUDENT INVESTSIGATOR
Name: 1st year M.A. student name
Department: Psychology
Title: Instructor
Degree Attained: B.A.
Email Address: 1st year M.A. student e-mail address
Street or Campus Address: 1st year M.A. student Kalamazoo address
City: Kalamazoo
State: MI
ZIP: 1st year M.A. student ZIP
Office Phone: (269) 387-4491
Home Phone: 1st year M.A. student phone number
Human Subjects web training at completed: Yes
Status and level of involvement of student investigator: Master level
CO-PRINCIPAL OR STUDENT INVESTSIGATOR
Name: 2nd year M.A. student name
Department: Psychology
Title: Instructor
Degree Attained: B.A.
Email Address: 2nd year M.A. student e-mail address
Street or Campus Address: 2nd year M.A. student Kalamazoo address
City: Kalamazoo
State: MI
ZIP: 2nd year M.A. student ZIP
Office Phone: (269) 387-4491
Home Phone: 2nd year M.A. student phone number
Human Subjects web training at completed: Yes
Status and level of involvement of student investigator: Master level
Your Undergraduate(s) is/are WMU investigators, so complete the “Additional WMU Investigators” form.
COLLABORATING INVESTIGATORS AND AFFILIATIONS: leave blank
IV. PROPOSED PROJECT DURATION:
From (mm/dd/yy): **/**/** [when project will be approved by HSIRB]
To (mm/dd/yy): **/**/** [12 months following approval by HSIRB]
V. TARGETED PARTICIPANT POOL
Total number of subjects: number of student members of system
Number of subjects in control group: 0
Age range (lower limit—upper limit, e.g., 18-99): age range of student members
Gender: Both
Targeted Race/Ethnicity: None/Not applicable
Inclusionary criteria: classification of student members, in Behavior Analysis Training System at Western Michigan University
Exclusionary criteria: none
Source of participants: Behavior Analysis Training System at Western Michigan University
Length of participation (x min/session, y sessions, over z months): over 12 months, no additional time
Targeted Participants in Special Consideration Categories: None
V. FUNDING
Funding source: None, No funding source
WMU proposal number for funded project: leave blank
Date of submission to funding agency: leave blank
VII. RESEARCH SITE(S)
Site(s) and organizations involved in data collection and/or research activity: Western Michigan University
Letters of approval from project site officials: are not needed (research on-campus)
VIII. PROTOCOL OUTLINE check all
These are the required headings for the protocol.
IX. CONSENT DOCUMENT DEVELOPMENT CHECKLIST check all
This is the required information for the consent document.
The following are to be included if appropriate: check: The approximate number of participants in the study
X. LEVEL OF REVIEW check: Administrative or Expedited
Educational setting/normal educational practice
XI. CERTIFICATION/SIGNATURE
All student investigators must sign and date before turning it in. Dr. Malott will sign it later.
Ask the 2nd year M.A. student for previously submitted HSIRB documents.
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