please answer all the questions. the reb will not review ... date (dd-mm-yyyy) date (dd-mm-yyyy) 4

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  • RESEARCH ETHICS BOARD PROJECT SUBMISSION FORM (adapted from the Ottawa University form, with Research Services’ authorization

    of the above mentioned University)

    This form must be used by all Saint Paul University researchers submitting to the Research Ethics Board (REB) for ethical review of their projects involving participation of human beings. Such research includes, without limitation, projects involving questionnaires, individual interviews, focus groups, testing of equipment, physical endurance tests, etc. For research based on secondary use of data, please click on the following link:

    http://web.ustpaul.uottawa.ca/en/research/forms%20htm/secondary%20use.htm

    SECTION A — GENERAL INFORMATION Title of the Project:

    Last Name First Name Initial(s)

    Faculty

    Telephone - work E-mail-work

    Internal Use

    Project Number

    Telephone - home (optional) E-mail-home (optional)

    ( )

    ( )

    ( )ext.

    1. Principal Investigator / Student

    Title � Professor � Doctor � Mrs. � Mr. � Other

    Preferred language of correspondence: � French � English

    Updated: 01/10/05

    Please answer all the questions. The REB will not review incomplete applications or documents other than those required.

    http://web.ustpaul.uottawa.ca/en/research/forms%20htm/secondary%20use.htm

  • 2. Co-investigator / Supervisor

    Note: If this is a 4th year research project, Master’s or Doctoral project or any other reseach project, indicate your supervisor’s name and coordinates here: Note: List all co-investigators or students involved in this research. Photocopy this page as needed. Please provide your permanent postal and e-mail addresses for future correspondence.

    Last Name First Name Initial(s)

    Faculty

    Telephone - work E-mail - work

    Telephone - home (optional) E-mail - home (optional)

    ( )

    ( )

    ( )ext.

    Title � Professor � Doctor � Mrs. � Mr. � Other

    Last Name First Name Initial(s)

    Faculty

    Telephone - work E-mail - work

    Telephone - home (optional) E-mail - home (optional)

    ( )

    ( )

    ( )ext.

    Title � Professor � Doctor � Mrs. � Mr. � Other

    Last Name Initial(s)

    Faculty

    Telephone - work E-mail - work

    Telephone - home (optional) E-mail - home (optional)

    ( )

    ( )

    ( )ext.

    Title � Professor � Doctor � Mrs. � Mr. � Other

    First Name

  • 3. Funding Information

    Did you ask for funding? � yes � no

    If yes, name of funding agency:

    Status of funding: � received � pending

    Expected date of beginning of the project: Expected date of completion of the project:

    Date (dd-mm-yyyy) Date (dd-mm-yyyy)

    4. Type of Research

    Professor’s Research

    Doctoral thesis

    Master’s thesis

    4th year project

    Other (specify)

    Note: Students conducting research for their Master’s or Ph.D. (or other) should append their thesis committee’s approval. The REB will not evaluate thesis-related proposals before the thesis committee has evaluated the project.

    Has this project been subject to a scientific evaluation? � yes � no

    If yes, indicate by whom this evaluation has been done?

    If no, explain the absence of the scientific evaluation?

    6. Multi-center Research

    Is this project under the responsibility of another center?

    If yes, which one?

    � yes � no

    Does this project involve one or more center(s)? � yes � no If yes, which one?

    5. Scientific Evaluation

  • Has this project received the ethical approbation of another establishment?

    6. Multi-centre Research (continued)

    If yes, include the copy or copies of the ethical approbation.

    � yes � no

    7. Risk Evaluation

    How do you evaluate the risk associated to your project as defined by the Tri-council Policy Statement?

    � minimal � more than minimal

    Note : Minimal risk as defined by the: The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS) (http://pre.ethics.gc.ca/english/policystatement/section1.cfm). The standard risk is commonly defined as follows: if potential subjects can reasonably be expected to regard the probability and magnitude of possible harms implied by participation in the research to be no greater than those encountered by the subject in those aspects of his or her everyday life that relate to the research then the research can be regarded as within the range of minimal risk. Above the threshold of minimal risk, the research warrants a higher degree of scrutiny and greater provision for the protection of the interests of prospective subjects. There is a similar threshold regarding undue or excessive offers of benefit. As an offer of payment in relation to research participation exceeds the normal range of benefits open to the research subject, it is increasingly likely to amount to an undue incentive for participation (see Section 2B). (...). Reference : http://pre.ethics.gc.ca/english/policystatement/section1.cfm

    � (Provide required document)

    http://pre.ethics.gc.ca/english/policystatement/section1.cfm http://pre.ethics.gc.ca/english/policystatement/section1.cfm

  • SECTION B - SUMMARY OF THE RESEARCH PROJECT 8. Research Project

    a) Rationale: Briefly describe the purpose, hypothesis and the objectives of the proposed research project (not exceeding 150 words).

    b) Methodology: Briefly describe chronologically all procedures in which the research participants will be involved in (e.g. paper and pencil tasks, interviews, surveys, questionnaires, physical endurance tests, etc.) Note: Please append a copy of all questionnaires, interview guides or other test instruments.

  • d) If the research involves only one particular group while excluding another, for example only women or men or only Francophones, indicate why such exclusion is appropriate for the study.

    e) Does your experimental procedure involve partial disclosure of information or the use of subterfuge?

    9. Recruitment

    b) When, how and by whom will participants be recruited? Note: Please append a copy of any tools to be used for recruitment (poster(s), advertisement(s), telephone scripts or letter(s) of information).

    8. c) Participants: Describe the number of participants being recruited and their characteristics (age group, gender, affiliation, etc.).

    Age Group

    Gender

    Affiliation

    Other characteristics

    � yes � no

    If yes, justify.

    a) List location(s) where participants will be recruited.

    Number of participants

  • 9. c) Are there any supervisory or other relationships between the researchers and the participants (e.g. professor-student; manager-employee)?

    If yes, please describe:

    d) Will you ask participating organizations to provide names of potential participants?

    If yes, how will the participants’ permission be obtained?

    e) Are participants recruited in organizations or in other premises where permission is required to access the potential participants or premises?

    � yes � no

    If yes, how will you obtain permission to access the premises? Note: Please append written permission by participating organizations.

    f) Will minors (0-17 years old) be asked to participate in the research?

    � yes � no

    If yes, please specify the age group(s):

    � yes � no

    � yes � no

  • 9. g) Consent from the parent or guardian is normally required if the child is less than eighteen years of age. This consent form must be submitted. If you are seeking an exemption to this requirement, please explain.

    h) In addition to parental/guardian consent, the child must also confirm his or her agreement to participate. This is normally done in writing with an assent form, drafted in age-appropriate language and must be submitted in addition to the parental/guardian consent form. If a child’s unwritten concurrence is sought, researchers must nevertheless obtain and document the child’s unwritten assent. If applicable, please explain below why unwritten assent of the child is necessary and the measures to be taken to obtain and document such unwritten assent.

    i) Are the participants in any other risk group (other than 9 f)

    � yes � no

    If yes, which one?

    10. Selection of the participants:

    a) Are inclusion or exclusion criteria in addition to those identified in question 8d, necessary for the research methodology?

    � yes � no, inclusion or exclusion criteria are necessary. All those who wish to participate will be included.

    If yes, explain how the screening of potential participants will be carried out and how the excluded candidates will be notified. Note: Please append a copy of any selection test or questionnaire, if applicable.

    How will the preselection be done? How will the excluded persons be advised?

  • 10. b) Is there a risk of negative reaction on the part of excluded candidates, or any other inconveniences for the excluded candidates?

    � yes � no

    If yes, describe the nature of such risks or inconveniences, and the m

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