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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