Research Observations Survey

Health and Human Services

RESEARCH OBSERVATIONS SURVEY

RESEARCH REQUEST / PRE-APPLICATION FORM

A. Approval Process

B. IRC Pre-Application Form

Please complete the form below so that we can make an initial determination of the feasibility and appropriateness of the proposed research for our environment. You will receive e-mail notification of the decision. If the research is deemed feasible, you will be asked to submit additional documents and you will be scheduled to attend a committee meeting. Our goal is to complete this process in 30 - 45 days.

1. Your information is automatically time-date stamped when you click SEND.
2. Application Type:
3. Title of Research Project:
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4. PRINCIPAL INVESTIGATOR INFO:
Title:
First Name:
Last Name:
Agency: School / Work Affiliation:
Work Phone:
Alt. / Cell Phone:
E-Mail:
Address:
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5. NAME OF INDIVIDUAL WITH DAILY OVERSIGHT OF THE STUDY:
First Name:
Last Name:
Work Phone:
Cell Phone:
E-Mail:
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6. Proposed Duration of Study:
Start:
Finish:
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7. Desired Research Site(s), if known:
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8. Does the study involve Human Subjects?
If YES, describe the target population and the proposed method of access:

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9. Is research neded to meet academic requirements?
If YES, please explain:

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10. BRIEF project description (250 words or less)

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11. Will you provide staff to implement the research activites at HDHHS?
If YES, total estimated man-hours:
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12. Will HDHHS staff have any responsibility in implmenting the research project?
If YES, list responsibilities and proposed frequency:

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13. List any additional equipment/logistical needs:

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14. Do you require access to HDHHS data?
If YES, please explain:

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15. What are your funding sources and funding period for this project?

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16. Comments / Additional Information (250 words or less)

If you do not receive a response from your pre-application, please contact the webmaster.