Agency Application Form

Agency Information

Agency Name(Required)

Phone(Required)

Email(Required)

Website

Address(es) of Location(s) where research will take place:

Address Line 1

Address Line 2

City

State

ZIP

Population Characteristics

Number of individuals served by Agency:

Age-Range of Clients

Is there a primary diagnosis of clients? If not, please describe the range of diagnoses treated.

Personnel Information

CEO/Director

First Last

Number of BCBAs employed by agency

Staff member designated as Research Coordinator at Agency:

First Last

Credentials/Licensure if applicable

This field is hidden when viewing the form

Research Background (HIDDEN)

Highest level of education achieved

Research Background (describe the research experience of the research coordinator)(Required)

Nomination of agency employee willing to serve in the future on the RRC

Guidelines and Regulations

Human Rights training in regards to human subjects in research must be completed by all who are conducting research. Which human rights training will be used for researchers at your organization?

Types of behavior-analytic research that will be conducted by the agency:

Other

Does your agency treat clients overseen by DMH-DD programs?(Required)

Yes

Does your agency have a Human Rights Committee?(Required)

Yes

Is your agency accredited through any other governing bodies? (CARF, BHOCE, ect…)(Required)

Yes

Please list the governing bodies:(Required)

Are you aware that any principle investigator or data collector must complete a human services training prior to conducting research and provide proof of completion to the RRC?(Required)

Yes

Are you aware that each project proposal will need to be approved by either the CEO / Director / or supervisor within the agency before submitting to the RRC?(Required)

Yes

Note: In the event that the agency’s research coordinator is no longer employed by the agency or the agency wishes to place a new individual in this role, the agency must submit a new application to the RRC specifying the person who will assume the research coordinator role.

The RRC will review the agency application and let the agency know in writing whether or not the application has been accepted. Agencies are allowed to resubmit the application based on the feedback provided.