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California State University, Long Beach

Institutional Review Board for the Protection of Human Subjects

Application for
Administrative Review* of Research Protocol

*Exempt from Review by the IRB
(Rev. 5/10/01)
First, you should print-out this page for reference. Second, you should copy this document onto your computer's hard drive by using the " F ile Save As" function. Copy the file without changing its name or file extension into a subdirectory you will remember, such as "university" or "research." Or, you may copy the Form contents into a new word-processing document using the "Edit Select All," then the "Edit Copy," and then the "Edit Paste" function sequence of your web browser (Netscape or MS Internet Explorer). Once you have the Form in your computer, open it in the normal way with your wordprocessing program, save it with your own file name, and then answer the questions into the existing text. Use as much space as your answer requires. This Form is a format. Answer the questions in the Administrative Review Decision Program until you complete the program, that is, until you have been advised whether your research is exempt from review by the IRB or not. If you have questions about the results, call 562-985-5314 before continuing with this application.
1. State the category of this research which you believe qualifies it as exempt from IRB review status. Refer to the University Policy Statement paragraphs 3900-4010 by number and give the category name as it appears in the Policy or in the Administrative Review Decision Program.
2. Your answers to the next questions will help the administrative reviewer substantiate this selection. Principal Researcher: (Name) Position: (Professor, M.A. thesis student, etc.): Faculty Department: Student Home Address: Daytime Telephone Number:
If you are a student: Thesis Advisor / Faculty Supervisor(name): Faculty University Telephone Number: Title of proposed research study: Research begins on (after Approval):
Ends on:
Location(s):
3. Hypothesis, methodology, research plan and activities: a. Describe the purpose(s) of the study, including research hypotheses, if any. b. Describe your research plan and methodology. c. Describe specifically what you will do with the subjects or, if this is an analysis of records, how you will obtain them and what information you will take from them.
4. Benefits: a. Describe any benefits to the subject(s) (persons represented in the data) which may reasonably be expected from the research, including sharing of research findings, where appropriate; b. Describe benefits, if any, to others. c. If applicable, describe the nature of any debriefing of subjects.
5. Risks: a. Describe the risks to human subjects, that is, the nature of any physical/medical risks, any psychological/discomfort risks, any risks to reputation, employability, insurability, and any risks to the privacy of subjects (anonymity, confidentiality, or neither). b. Describe the safeguards that will be employed to diminish or eliminate these risks. c. Describe the method and duration of storage and disposal of consent forms and data.
6. Human Subject Characteristics:
a. Indicate the proposed number of subjects (or records) by age group:0 through 67 through 1718 and older
   
b. Is any human subject known to have developmental disabilities, mental illness, or is under any form of legal guardianship of adults?
Yes    No   
7. Recruitment Sources:
From what source(s), e.g., hospitals, institutions, schools, classes, shopping malls, etc. will subjects be drawn into the research? If this is a review and analysis of records only, state the source of the records.
  • Attach original letters of approval (on their letterhead with the exact title of your research) from all participating organizations, indicating the nature and extent of their participation.
8. Recruitment Process:
What process will you use to invite people to participate in your research? Describe the complete sequence of events from initial approach to the point where you have obtained Informed Consent.
  • Attach a copy of all materials used to recruit subjects (informed consent forms, advertisements, flyers, telephone scripts, verbal recruitment scripts, cover letters, etc.)
  • Attach copy(ies) of all proposed consent form(s) in all languages used. Check the model informed consent document to assure that you have all the elements of consent in your consent form.
If this research is review and analysis of records only, please indicate to the best of your knowledge whether informed consent or privacy release was obtained at the time the record was prepared.
9. Research Tools:
Identify, give the source of, and attach a copy of any tests, questionnaires, or other materials to be used.
10. Researcher Qualifications:
Briefly describe the training and experience that qualifies you to carry out the proposed research.

Submit Application packet to the Office of University Research,
University Foundation Building, Suite 310.
Telephone (562) 985- 5314.

Student thesis research, independent/directed study, and independent/directed research require completion of the Faculty Supervisor Form . Please begin this form for your faculty supervisor and present it with the completed application form.