OIE IRB Request Form

Step 1 of 4 - General Information

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To apply for research approval at Pasadena City College, you will be required to submit this Research Review Form.
Section A
General Information
Title of Project*
Principal Investigator (PI)*
First Last
Institution*
Email*
Enter Email Confirm Email
Phone*
Co-investigators
Anticipated date(s) of data collection*

Section B
I. Research Summary
Please describe the purpose/goals of the research and any hypotheses or expected outcomes of the study. Describe the scientific need or rationale for this study and the importance or significance of the knowledge to be gained*
(500 words or less)
II. Participants and Recruitment
Who is your intended population?*
- PCC Administrators
- PCC Staff
- PCC Faculty
- PCC Students
Identify any Vulnerable Populations you intend to recruit*
- Children under 18 (need parent consent and child assent)
- Senior Citizens (65 and older)
- Pregnant women
- People with disabilities
- Currently incarcerated students
- N/A
- Other
Other vulnerable population you intend to recruit*
Describe the proposed participant population*
Include the approximately number of participants and specific demographics. Clearly note all inclusion/exclusion criteria for participation and reasons for such inclusion/exclusion. Note if any special vulnerable populations will be purposefully sampled.
Describe recruitment procedures*
If conducting experimental procedures on campus, note the location of the procedure. Clearance from instructors is required if experimental procedures will take place in class. If off campus, note whether permission has already been obtained and attach a letter of permission. Indicate when the experimental procedures will take place. Describe how any perceptions of coercion (e.g., students must participate in a survey to get extra credit) by the potential participants will be mitigated. Describe any compensation or incentives offered to potential participants.
Attach all recruitment documents
(flyers, recruitment scripts etc.)
Drop files here or
Describe the process for gaining informed consent and/or assent*
Submit a copy of the written consent/assent form, as well as the debriefing form
Drop files here or
III. Protocols and Methodology
Describe the data collection procedures and materials*
Indicate how potential participants will be identified and selected.
Attach copies of materials to be used in final form to the extent possible
(e.g., questionnaires, interview protocols, etc.)
Drop files here or
Elaborate on the procedures that ensure the protection of the identity of participants and in general how confidentially will be maintained*
TIPS: Where the information will be stored, for how long, and who will have access. Describe the final disposition procedures (will documents be shredded?) For recordings/video, indicate who will transcribe, when, and final disposition of materials
IV. Potential Risk and Benefits
Describe potential risks to participants. Ensure that you indicate the following:
- Any apparatus will be applied externally or internally to participants
- Any drugs or special diet will be administered to participants
- Participants will be exposed to any stimuli that might be physically or mentally harmful
- Participants will experience any stress or discomfort
- The information gathered could expose participants to liability, discrimination or embarrassment
- Any deception will take place and debriefing
If any of the above will take place, indicate why such procedure is necessary and describe steps that will be taken to mitigate any harm. Lastly, describe any corresponding safeguard for any potential risks*

Section C
Institutional Affiliation
Provide the following regarding your IRB approval from the institution with which you are affiliated.
Institution*
Do you have a faculty advisor?*
- Yes
- No
Faculty Advisor*
Faculty Advisor Email*
Enter Email Confirm Email
Have you contacted someone at PCC to sponsor/assist with your research?*
- Yes
- No
PCC Contact*
First Last
Department*

Section D
Documents and Acknowledgement
Please indicate what documents you will be uploading
- IRB approval from external institution, including application documents
- Recruitment documents (flyers, letters/e-mails of solicitation, etc.) if applicable
- Consent form
- Assent form, if applicable
- Data collection instruments (questionnaires/surveys, interview/focus group protocols, etc.)
Please include any related documents that will be used in this study
e.g., consent forms, interview protocols, surveys/questionnaires, recruitment e-mails etc.
Drop files here or
Acknowledgement*
- By checking this box, the Principle Investigator certifies that the information on this form is accurate and that s/he: 1) will comply with federal and institutional policies and procedures to ensure the protection of human subjects in research, 2) understands his/her ethnical responsibilities as a researcher, 3) will have completed the CITI Program Training on human subjects research and responsible conduct of research before the study begins, 4) will contact PCC Office of Institutional Effectiveness prior to making any changes to the proposed research study, 5) will promptly inform PCC Office of Institutional Effectiveness of any unanticipated problem that may jeopardize the well-being of participants, and 6) will contact PCC Office of Institutional Effectiveness 10 months after the study’s approval to provide an update on the study’s status and the need for a possible one-year renewal.
Phone
This field is for validation purposes and should be left unchanged.