INSTITUTIONAL REVIEW BOARD

COVER SHEET FORM

APPLICATION CATEGORY

EXPEDITED FULL REVIEW MODIFICATION

PROTOCOL #___________

TYPE OF RESEARCH

Graduate Undergraduate Faculty Other, Specify ________________

PRINCIPAL INVESTIGATOR ________________________________________________________________________________

FACULTY STAFF STUDENT

PROJECT TITLE __________________________________________________________________________________________

__________________________________________________________________________________________________________

PROPOSED PROJECT PERIOD: From __________________________ To: ________________________________

MAILING ADDRESS: _______________________________________________________________________________________

E-MAIL:____________________________ PHONE:____________________________
__________________________________________________________________________________________________________

NAME OF RESEARCH ADVISOR (if student): ___________________________________________________________________

E-MAIL:____________________________________

OUTSIDE AGENCY INFORMATION

NAME OF INSTITUTION COLLECTING DATA:_________________________________________________________________

ADDRESS:_________________________________________________________________________________________________

PHONE NUMBER OF PRINCIPAL INVESTIGATOR:_____________________________________________________________

SPONSOR INFORMATION

GRANT SUPPORT/FUNDING YES NO If yes, budget amount $_______________________________________

NAME OF FUNDING AGENCY:_______________________________________________________________________________

RESEARCH METHODS AND PARTICIPANTS (Please check all that apply)

Questionnaire/Survey Interview Data Banks Videos Recordings Files Observation

Internet Survey Test Task Other ___________________________________________

PARTICIPANTS (BE SPECIFIC):_____________________________________________________________________________

NUMBER OF EXPECTED PARTICIPANTS: _____________________________

SIGNATURE OF PRINCIPAL INVESTIGATOR __________________________________ DATE _________________________

SIGNATURE OF FACULTY ADVISOR __________________________________ DATE _________________________

For Office Use Only: APPROVED RESUBMIT WITH MODIFICATION DENIED

COMMITTEE SIGNATURE:____________________________________________________________________DATE__________