þ7#)_6A'Y4 4 4 4 4 4¸4¸4¸4¸ 4Ä 4Î 4Ø4Ø4Ø4Ø4Ø 5L4ø4ø4ø6#5L×6%6)4øT6-6/6367696=Statement of Intention to Engage in Human Subjects Research Union College (Type or Print Neatly) Title of Proposal:__________________________________________________________ Student Signature(s): ______________________________________________________ Faculty Signature: ________________________________________________________ (Do Not Write Below This Line) ------------------------------------------------------------------------------------------------------------ The above proposal (check one): _______ Has been given Expedited Approval by the Chairperson of the Human Subjects Committee. You may proceed with the experiment, subject to any qualifications listed below: _______ Has been given approval by the full Human Subjects Committee. You may proceed with the experiment, subject to any qualifications listed below: ______ Has not been approved by the Human Subjects Committee for the reasons given below. __________________ Initials of Chairperson Qualifications or reasons for rejection. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Statement of Intention to Engage in Human Subjects Research (Answer Questions 1-18) 1. Name of researcher(s): _________________________________________________________________ Box number and/or address: _____________________________________________________________ Phone and Email address: _______________________________________________________________ 2. Name of faculty sponsor of student research: ________________________________________________ Department: __________________________________________________________________________ Phone and Email address: _______________________________________________________________ 3. Title of research project: ________________________________________________________________ 4. Is this research funded: (check one) ___yes ____ no If yes, by whom? ______________________________________________________________________ 5. Characteristics of the subjects: Approximate number of subjects: ______________________________ Age of subjects: __________________ Sex of subjects: M ____ F ____ Both ________ Other important characteristics (e.g., prisoners, subjects in poor mental or physical health, etc.). _____________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________________________________________ 6. Location of data collection (e.g., place where interviews, observations, etc., will occur). _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 7. If data collection is to occur at a location other than Union College (e.g., at another college, at an elementary school, or at a business location), describe how you have secured permission from the appropriate individuals at the other location(s). _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Statement of Intention to Engage in Human Subjects Research 8. How will the subjects be sampled, recruited or otherwise enlisted as participants in this study? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 9. Describe the manner in which informed consent will be obtained. If informed consent will not be obtained, please explain why it will not be obtained (e.g., to safeguard the anonymity of participants). In most research projects written informed consent is required (see Title 45, Part 46.116). Attach a copy of your informed consent form to this proposal. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 10. How will the anonymity of participants and/or the confidentiality of the data be ensured? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Statement of Intention to Engage in Human Subjects Research For items 11-16, respond by circling ÒYesÓ or ÒNo.Ó If the answer is ÒNoÓ, provide a justification for the action to which the question refers. Yes No 11. To the best of my knowledge, none of the human subjects likely to participate in this research will be placed at risk with regard to physical pain or discomfort, psychological stress or discomfort, or social injury. Social injury is understood here to mean such conditions as diminished reputation, or damaged social and personal relationships. If No, please explain: Yes No 12. Information that might affect subjectÕs willingness to participate will not be withheld from them prior to the securing of their consent to take part in the research. If No, please explain: Yes No 13. No coercion or penalties which might negate a subjectÕs freedom to refuse to participate in the experiment or to withdraw voluntarily from participation will be used, and it will be made clear at the onset to participants that they shall be free to withdraw at any time. If No, please explain: Yes No 14. All promises and commitments made to subjects concerning their participation will be duly honored by the researcher. If No, please explain: Yes No 15. Following their participation, all subjects will be provided with a complete explanation of the nature of the study so as to eliminate possible misconceptions about its purpose and to eliminate any stress or discomfort experienced by participants. If No, please explain: Yes No 16. To the best of my knowledge none of the student researchers who will be conducting the research will be placed at risk with regard to physical pain or discomfort, or psychological stress or discomfort. If No, please explain measures taken to minimize the risk to student researchers. 17. In addition to the specific explanations which may have been provided in conjunction with ÒNoÓ answers to questions #11-16, please provide any further comments which might help the Review Committee determine whether the proposed research is likely to produce benefits so significant as to outweigh any questionable or risk-producing research procedures. 18. Please provide a description of your study, explaining the purpose and the procedures. Do not simply attach a copy of your IEF proposal. Rather, the Review Committee would like a detailed description of the procedures of your study, so that we can evaluate potential risks to the human subjects. If a questionnaire is to be used, a copy must be included with the application. If an interview procedure is to be used, the types of questions that will be asked should be described. If deception is used, you must explain either how the subject will be debriefed or why they will not be debriefed. u~€‚hƒh„h‚h<J”— & ' b |bos€™d¼ô/0¨©ë'W’“”$$Š'¶'ê(U(Y)Y)\)_ûø÷ôïìçäßÜÙÖÓÒÏÌÉÄÁ¾»¶±¬© €€   €&<Jab¯°ý\¬:;ìíˆãäåaâã  ef½¾noÆÇ  w x Ô Õ c { | Ú Û : ; œ  ^ _ ¸ ¹   Z [ º »$%ûöðÜÜÜÜÜÜÜÜÜÜÜÜÜÜÖÖÐÐʶ¶¶úðýÀܲˆ ³`¨hhúðýÀܲˆ ³è¨ÿC%š›cd¼Â~×Ø/0‡ˆóY‘éêAB™šòó012—¡øùPQ¨©ë××××××××®®®®®®®®®®®®®®®®®®®®š†††††††††sÿúðýÀܲˆ ³è¨úðýÀܲˆ ³è¨úðýÀܲˆ ³è¨úðýÀܲˆ ³è¨úðýÀܲˆ ³è¨ÜúðýÀܲˆ ³è¨úðýÀܲˆ ³`¨h)©XY°±…æ)*‚ÙÚ12‰Šáâ9:;š›ñòHIŸ ö÷MN¥¦ýþUVW“”,-›œÏÐÑÒÓÔÕÖììììììììììììììììììììììÚÚÚÆÆÆÆÆÆÆÆÆÆÆÆÆÆÆÆÆƳŸ™‘‘‘‘‘‘‘‘‘‘ ù@ù@úðýÀܲˆ ³è¨ÿúðýÀܲˆ ³è¨úðýÀܲˆ ³è¨úðýÀ²ˆ ³è¨úðýÀܲˆ ³è¨9Ö ’ “ Ç È É Ê Ë Ì Í!ð!ñ"'"(")"*"+","-"."·"¸"ì"í"î"ï"ð"ñ#þ#ÿ$3$4$5$6$7$8$9%%%Š%‹%Œ%%Ž%%%‘%’&ù&ú&ü)Y)[)\)])^)_øøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøððððððððåß×ÌÁ»»° HHþ˜ÿ % @ HHþ˜þPþà HHþ˜°ý0 ù@8 ÿÿÿÿÿÿÿÿÿÿcaptionÿÿÿÿÿÿÿÿÿÿ€€Nóà!À @ôà!À @ÿÿÿÿÿÿÿÿÿÿ ÿ óôÞW'_)_)o)_)_=à/Ð hÐBT;Statement of Intention to Engage in Human Subjects ResearchAcademic Computing Times New RomanSymbol{Times New Roman CE|Times New Roman Cyr~Times New Roman GreekTimes New Roman Tur€Times New Roman (Hebrew)Times New Roman (Arabic)‚Times New Roman Baltic'_'_