APPLICATION FORM

Institutional Review Board – IRB

Exempt Complete Sections 1 – 6 and 16

Review (Expedited or Full Board) Complete all sections

Project Title: Date 1 PROJECT INFORMATION

of Request:

Name and Degree(s): 2 PRINCIPAL INVESTIGATOR

Department/Center:

Mailing Address:

Email: Phone #: Fax:

University Affiliation:

Professor

Associate Professor

Assistant Professor

Instructor

Other: Please specify.

3 CO-INVESTIGATORS (CO-I)
 A Co-I is anyone who has responsibility for the project’s design, implementation,
data collection, data analysis, or who has contact with study participants.

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 If the project involves medical procedures or patient care that the PI is not
certified or licensed to conduct, a responsible physician or other certified or
licensed professional must be included as a Co-I. The application must include a
copy of supporting documentation for this individual (CV, license, board
certification etc).
Name Affiliation Department Email/Tel/Fax

4 SUMMARY
Please include a summary answer for eachOFofPROJECT
the questions. Use as much space as
necessary AND attach a copy of the study proposal or project.

If you attach a copy of the full proposal, place page and paragraph numbers from
the proposal next to each question in this section to show precisely where information
pertaining to each question can be found. Please note that information should be
consistent throughout all relevant documents.

How will study results be used?

What is the hypothesis?

Describe study procedures and methodologies.

What are the participant selection criteria?

Describe the steps that will be taken to ensure the confidentiality of the
participants and data.

5 STUDY
What is the expected duration of the DURATION
study through data analysis? (Attach a
timeline, if applicable)

What is the expected date that recruitment will begin? (Must be after the
submission date)

6 DATA SOURCES AND USES

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a) Please check all the ways that you will obtain data: (Copies of written and
oral questions must be provided for ADU IRB review. The questions must be
approved prior to implementation.)

Interviews Questionnaires/Surveys

Focus Groups Public Records

Medical Records Biological Specimens

Registries Other (please describe)

b) How will the data be used? (Check all that apply)

Dissertation Publication/journal article

Thesis Undergraduate honors project

Results released to participants/parents Results released to employer or
school (please describe)

Results released to agency or organization (Please describe)

Conferences/presentations Other (please describe):

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These sections should only be completed in case of an IRB review, not an
application for exemption.

7 PROJECT FUNDING
How is the research project funded?
Research is not funded
Funding decision is pending
Research is funded

A copy of the grant application must be provided prior to IRB approval

8 STUDY
Where will the study be conducted? (Check all thatSITES
apply)

On campus (Please indicate building(s) and room number (s) if known)

Off campus (Please provide location and letter of permission, where applicable)

9 INTERNATIONAL
a) Does this study include an international site? RESEARCH
Yes (list country)

No

b) If this is an international study, please provide a statement including the

following items:

 The investigator’s familiarity with the culture in which the study is taking
place.
 Cultural norms relevant to the project and how this study may affect an
individual’s standing in his/her community.
 The standard of health care in the community if relevant, how the proposed
research procedures will differ, and a plan for the continuation of care once
the research is complete.

10criteria?
a) What are the inclusion RESEARCH PARTICIPANT
(Use an expended list and attach a secondary
sheet with explanation, where applicable. If you attach a secondary sheet,
reference on which page the information can be found.)

b) What are the exclusion criteria?

c) Please explain recruitment procedures in detail. (A copy of the recruitment

materials must be attached.)

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d) What is the expected duration of participation of each individual? (total and
at each session)

e) What is the expected number of individuals to be screened for

enrollment?

f) What is the maximum number of individuals to be enrolled? (This

includes individuals who drop out)

g) If the following criteria are important to the program, please describe

What is the approximate number of:

Males Females

Indicate the age range of the participants that you plan to enroll in your
study. to

What is the race of participants?

h) Does the study target any of the following participants?

Yes (please check all that apply) No

Children (under 18)

Pregnant women

Mentally Challenged

Economically disadvantaged

Prisoners or detainees

Persons at high risk of becoming detained or imprisoned

Fetuses

Patients, if yes – what is the status of their health?

Participants who have low-literacy (describe the means used to ensure the
participants’ understanding of the research)

Non-English speakers (describe the means used to ensure the

participants’ understanding of the research)

i) If any of the above categories have been checked, please state how you will
protect the rights and privacy of these individuals.

11 COMPENSATION

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a) Will any type of compensation be used? (e.g. money, gift, raffle, etc.) Yes

(Please describe the kind of compensation):

No

b) Explain why the compensation is reasonable in relation to the of and burden on

participants.

c)Is compensation for participation in the study or completion of the study? (Note:
participants must be free to quit at any time without penalty).

Participation Completion

d) If some or all participants are economically disadvantaged, explain how the

compensation is provided in such a way that participants can refuse the request to
participate?

12 RISKS
Please reference the proposal, AND BENEFITS
where applicable and answer the questions below.

a) What are potential risks to participants?

b) What steps will the investigators take to reduce risks?

c) What are any potential benefits to participants?

d) Please note how the results of the study will affect the health and welfare of the
general public.

e) What are the costs, if any, to participants? (This should be mentioned in the
consent form):

13will
Describe the specific steps you CONFIDENTIALITY
take to ensure the confidentiality of the
participants and data.

a) How will you safeguard data that includes potentially identifying information (e.g.
coding)?

b) When will identifiers be separated or removed from the data?

c) Where on campus will you store the data and media and ensure its security
(videotapes and/or audiotapes)?

d) How long do you plan to retain the data?

e) How will you dispose of the data?

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f) Is a certificate of confidentiality required? Yes No

Describe the procedures you 14 INFORMED

will use to CONSENT
obtain and document informed consent and
assent. Attach copies of the forms that you will use. Fully justify any request for a waiver
of written consent or parental consent for minors.

15 personnel
Does the investigator or key CONFLICT OF aINTEREST
have potential conflict of interest in this study?

Yes No (If yes, please describe and disclose in the consent form)

16 REQUIRED SIGNATURES
By signing this application form:

• I agree to accept responsibility for any impact to the rights and welfare of the
human subjects involved with this study as a result of my research.

• I believe that the benefits outweigh the risks to the participants in this study.

• I have read Abu Dhabi University IRB policy and guidelines and I agree to
comply with them.

• I certify that, to the best of my knowledge, I am in compliance with ADU’s IRB

policies and its related guidelines.

Principal Investigator Date

Attach a copy of the PI’s CV unless one is already on file.

Dean Date Print Dean Name

(If the PI is the Dean, the application must be signed by another authorized
Department/ School/College level Administrator)

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 If you have any queries on this form, please contact your Faculty Ethics Coordinator or visit the
website at ………………………………………………………………

Please email or send this form to the appropriate Faculty Ethics Coordinator
at: [email protected]

For office use only:

The appropriate Ethics Committee has considered the ethical aspects of this proposal.
The committee recommends that the program/project be:

Approved

Deferred (for reasons attached)

Not approved (for reasons attached)

Name of Committee Member:

Signed:

Date:

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Reviewer comments:

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